MEDICARE: HODGES PHYSICAL MEDICINE LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CH8853	FL
2	111N00000X	Chiropractor	CH0001278	FL
3	111N00000X	Chiropractor	CH9264	FL

General Provider Information

NPI Number	:	1477702652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HODGES PHYSICAL MEDICINE LLP

Provider Business Mailing Address
First Line	:	13947 BEACH BLVD
Second Line	:	SUITE 202
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224-1270
Country	:	US
Telephone Number	:	904-223-3330
Fax Number	:	904-223-4560

Provider Business Practice Location Address
First Line	:	13947 BEACH BLVD
Second Line	:	SUITE 202
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224-1270
Country	:	US
Telephone Number	:	904-223-3330
Fax Number	:	904-223-4560

Authorized Official
Title or Position	:	OWNER/CHIROPRACTOR/BUSINESS MANAGER
Name	:	DR. RICHARD RAY BLOOM SR.
Credential	:	D.C.
Telephone Number	:	904-223-3330

Provider Enumeration Date	:	09/12/2008
Last Update Date	:	09/12/2008

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