Healthcare Provider Details

I. General information

NPI: 1326850660
Provider Name (Legal Business Name): SAMUEL JACOB HOFHENKE RAD-T1
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 GREAT JONES ST
FAIRFIELD CA
94533-6005
US

IV. Provider business mailing address

623 GREAT JONES ST
FAIRFIELD CA
94533-6005
US

V. Phone/Fax

Practice location:
  • Phone: 707-451-9703
  • Fax:
Mailing address:
  • Phone: 707-451-9703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1536891123
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: