Healthcare Provider Details

I. General information

NPI: 1154854255
Provider Name (Legal Business Name): CHAD RAY HODGE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

IV. Provider business mailing address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

V. Phone/Fax

Practice location:
  • Phone: 337-312-8328
  • Fax: 337-433-2031
Mailing address:
  • Phone: 337-312-8258
  • Fax: 337-312-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN136771
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP09641
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: