MEDICARE: MODERN ALLY COMPANY, 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1902390149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN ALLY COMPANY, LLC

Provider Business Mailing Address
First Line	:	1545 S BREIEL BLVD STE E
Second Line	:
City	:	MIDDLETOWN
State	:	OH
Zip	:	45044-6703
Country	:	US
Telephone Number	:	937-321-5583
Fax Number	:

Provider Business Practice Location Address
First Line	:	1545 S BREIEL BLVD STE E
Second Line	:
City	:	MIDDLETOWN
State	:	OH
Zip	:	45044-6703
Country	:	US
Telephone Number	:	937-321-5583
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MRS. COURTNEY MOORE
Credential	:
Telephone Number	:	937-321-5583

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	06/20/2018

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