MEDICARE: MR. GEORGE A. MODRECK CCC-A

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	231H00000X	Audiologist	399	CO

General Provider Information

NPI Number	:	1558577254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GEORGE A. MODRECK CCC-A

Provider Business Mailing Address
First Line	:	9858 GLADES RD
Second Line	:	STE D
City	:	BOCA RATON
State	:	FL
Zip	:	33434-3983
Country	:	US
Telephone Number	:	303-984-4414
Fax Number	:	303-984-6244

Provider Business Practice Location Address
First Line	:	1399 S HAVANA ST
Second Line	:	STE 102
City	:	AURORA
State	:	CO
Zip	:	80012-4020
Country	:	US
Telephone Number	:	303-984-4414
Fax Number	:	303-984-6244

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	10/25/2016

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