=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619317443
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HODES CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2013
-----------------------------------------------------
Last Update Date | 03/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1249 W MAIN ST SUITE 7
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-754-2300
-----------------------------------------------------
Fax | 203-754-2301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1249 W MAIN ST SUITE 7
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-754-2300
-----------------------------------------------------
Fax | 203-754-2301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SCOTT A HODES
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 203-754-2300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 000899
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------