MEDICARE: MODERN CHIROPRACTIC PC

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	X009246	NY

General Provider Information

NPI Number	:	1396750972
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN CHIROPRACTIC PC

Provider Business Mailing Address
First Line	:	3062 BRIGHTON 3RD ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-7409
Country	:	US
Telephone Number	:	917-817-9244
Fax Number	:	718-743-9680

Provider Business Practice Location Address
First Line	:	3062 BRIGHTON 3RD ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-7409
Country	:	US
Telephone Number	:	917-817-9244
Fax Number	:	718-743-9680

Authorized Official
Title or Position	:	OWNER
Name	:	DIANA VAVIKOVA
Credential	:	D.C.
Telephone Number	:	917-817-9244

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	12/11/2007

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