MEDICARE: THE MODERN CHIROPRACTIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1154805869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE MODERN CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	4435 EDGEWATER DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-1229
Country	:	US
Telephone Number	:	571-212-9981
Fax Number	:

Provider Business Practice Location Address
First Line	:	4435 EDGEWATER DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-1229
Country	:	US
Telephone Number	:	571-212-9981
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	ALIREZA OSTOVAR
Credential	:	DC
Telephone Number	:	571-212-9981

Provider Enumeration Date	:	09/18/2018
Last Update Date	:	09/18/2018

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