MEDICARE: DAVIN RAY MODISETTE

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	247100000X	Radiologic Technologist	487010	TN

General Provider Information

NPI Number	:	1356721245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVIN RAY MODISETTE

Provider Business Mailing Address
First Line	:	23 WESTHAVEN PL
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-1758
Country	:	US
Telephone Number	:	318-475-0690
Fax Number	:

Provider Business Practice Location Address
First Line	:	23 WESTHAVEN PL
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-1758
Country	:	US
Telephone Number	:	318-475-0690
Fax Number	:	731-435-3385

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	12/28/2022

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Directions to “ DAVIN RAY MODISETTE ” Practice Location

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