Provider Demographics
NPI:1316351125
Name:K. VICTORIA MODICA, N.D., PLLC
Entity type:Organization
Organization Name:K. VICTORIA MODICA, N.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:V
Authorized Official - Last Name:MODICA
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:877-513-8012
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-943-4180
Mailing Address - Fax:
Practice Address - Street 1:3716 PACIFIC AVE
Practice Address - Street 2:SUITE H
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7836
Practice Address - Country:US
Practice Address - Phone:877-513-8012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:K. VICTORIA MODICA, N.D., PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60336456332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site