Provider Demographics
NPI:1164146684
Name:JEFFREY R HODGSON MD CORPORATION
Entity Type:Organization
Organization Name:JEFFREY R HODGSON MD CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:HODGSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-305-9378
Mailing Address - Street 1:PO BOX 353
Mailing Address - Street 2:
Mailing Address - City:FIDDLETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95629-0353
Mailing Address - Country:US
Mailing Address - Phone:312-305-9378
Mailing Address - Fax:
Practice Address - Street 1:20100 QUARTZ MOUTAIN ROAD NORTH
Practice Address - Street 2:
Practice Address - City:FIDDLETOWN
Practice Address - State:CA
Practice Address - Zip Code:95629
Practice Address - Country:US
Practice Address - Phone:312-305-9378
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility