Healthcare Provider Details

I. General information

NPI: 1326419979
Provider Name (Legal Business Name): GEOFFREY LANDIS WALKER HODGKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 THORNDIKE ST # 2
BROOKLINE MA
02446-5873
US

IV. Provider business mailing address

166 THORNDIKE ST # 2
BROOKLINE MA
02446-5873
US

V. Phone/Fax

Practice location:
  • Phone: 617-276-7521
  • Fax:
Mailing address:
  • Phone: 617-276-7521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: