MEDICARE: HODGE'S GROUP HOME, INC

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477922417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HODGE'S GROUP HOME, INC

Provider Business Mailing Address
First Line	:	4001 KALUGA PARK ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32808-7473
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4001 KALUGA PARK ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32808-7473
Country	:	US
Telephone Number	:	407-496-7356
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DEBORAH HODGE
Credential	:
Telephone Number	:	407-496-7356

Provider Enumeration Date	:	09/21/2015
Last Update Date	:	09/21/2015

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