Provider Demographics
NPI:1528677499
Name:MODI, MILAN (DC)
Entity type:Individual
Prefix:DR
First Name:MILAN
Middle Name:
Last Name:MODI
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 1:3929 CYRUS CREST CIR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-2521
Mailing Address - Country:US
Mailing Address - Phone:618-207-9565
Mailing Address - Fax:
Practice Address - Street 1:3225 SHALLOWFORD RD STE 700
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-7026
Practice Address - Country:US
Practice Address - Phone:770-353-9339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010314111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor