Healthcare Provider Details

I. General information

NPI: 1962423335
Provider Name (Legal Business Name): ERIC BOONE HODGES OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

487A N MAIN
THAYNE WY
83127
US

IV. Provider business mailing address

PO BOX 860 487A N MAIN
THAYNE WY
83127-0860
US

V. Phone/Fax

Practice location:
  • Phone: 307-883-8877
  • Fax: 307-883-8876
Mailing address:
  • Phone: 307-883-8877
  • Fax: 307-883-8876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR-538
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: