Healthcare Provider Details

I. General information

NPI: 1336443159
Provider Name (Legal Business Name): HODGEWOOD HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2011
Last Update Date: 01/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 S LAUREL RD
LONDON KY
40744-8550
US

IV. Provider business mailing address

PO BOX 2421
LONDON KY
40743-2421
US

V. Phone/Fax

Practice location:
  • Phone: 606-312-3736
  • Fax:
Mailing address:
  • Phone: 606-312-3736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberPENDING
License Number StateKY

VIII. Authorized Official

Name: THELMA WOODY
Title or Position: REGISTERED AGENT/MEMBER
Credential:
Phone: 606-312-3736