Provider Demographics
NPI:1861805376
Name:MODERN FAMILY CHIROPRACTIC, PLLC
Entity type:Organization
Organization Name:MODERN FAMILY CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:GOMES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:586-580-1234
Mailing Address - Street 1:13919 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313
Mailing Address - Country:US
Mailing Address - Phone:586-580-1234
Mailing Address - Fax:
Practice Address - Street 1:13919 19 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313
Practice Address - Country:US
Practice Address - Phone:586-580-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010048111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty