Provider Demographics
NPI:1902344591
Name:MODERN MOJO
Entity Type:Organization
Organization Name:MODERN MOJO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-999-7750
Mailing Address - Street 1:28 NW 4TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2714
Mailing Address - Country:US
Mailing Address - Phone:218-999-7750
Mailing Address - Fax:
Practice Address - Street 1:28 NW 4TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2714
Practice Address - Country:US
Practice Address - Phone:218-999-7750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)