Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 1352 | TN |
Y | 111N00000X | Chiropractor | DC0000001352 | TN |
N | 111NN0400X | Neurology | DC0000001352 | TN |
N | 111NN1001X | Nutrition | DC0000001352 | TN |
N | 111NR0200X | Radiology | DC0000001352 | TN |
N | 213ER0200X | Radiology | DC0000001352 | TN |
N | 111NR0400X | Rehabilitation Chiropractor | DC0000001352 | TN |
N | 111NS0005X | Chiropractic Sports Physician | DC0000001352T | TN |
N | 111NX0800X | Chiropractor Orthopedic Specialist | DC0000001352 | TN |
NPI | 1932258191 |
---|---|
Provider Name | Dr. Randy D. Modglin |
First Address | Johnson City, TN 37604-2492 |
Second Address | Johnson City, TN 37604-2492 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/01/2007 |
Last Update Date | 24/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3074458 | BLUE CROSS BLUE SHIELD (01) | TN |
350052904 | RAILROAD MEDICARE (01) | |
U65510 | (02) |