Provider Demographics
NPI:1548300932
Name:MODORY, GRANT LOUIS (DC)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:LOUIS
Last Name:MODORY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 HESTER ST W
Mailing Address - Street 2:
Mailing Address - City:DUNDAS
Mailing Address - State:MN
Mailing Address - Zip Code:55019-3970
Mailing Address - Country:US
Mailing Address - Phone:507-645-0333
Mailing Address - Fax:507-645-4047
Practice Address - Street 1:303 HESTER ST W
Practice Address - Street 2:
Practice Address - City:DUNDAS
Practice Address - State:MN
Practice Address - Zip Code:55019-3970
Practice Address - Country:US
Practice Address - Phone:507-645-0333
Practice Address - Fax:507-645-4047
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4075111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN54F47MOOtherBCBS INDIVIDUAL PROVIDER#
MN54F46COOtherBLUECROSS BLUESHEILD
MNCO3131Medicare UPIN