Provider Demographics
NPI:1811744907
Name:MODERN MAN TRT LLC
Entity type:Organization
Organization Name:MODERN MAN TRT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HORTAREAS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:619-356-8973
Mailing Address - Street 1:4306 W POINT LOMA BLVD APT D
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-1165
Mailing Address - Country:US
Mailing Address - Phone:619-356-8973
Mailing Address - Fax:
Practice Address - Street 1:4306 W POINT LOMA BLVD APT D
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-1165
Practice Address - Country:US
Practice Address - Phone:619-356-8973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty