1801106299 NPI number — MODUS VIVENDI CHIROPRACTIC PLLC

Table of content: (NPI 1801106299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801106299 NPI number — MODUS VIVENDI CHIROPRACTIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODUS VIVENDI CHIROPRACTIC PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ACTIVE FAMILY WELLNESS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801106299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4927 S COLLINS ST STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76018-1167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-557-2770
Provider Business Mailing Address Fax Number:
817-557-1795

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4120 N COLLINS ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76005-4554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-557-2770
Provider Business Practice Location Address Fax Number:
817-557-1795
Provider Enumeration Date:
10/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GODWIN
Authorized Official First Name:
KENYON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
817-557-2770

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  11576 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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