Provider Demographics
NPI:1528396199
Name:HODGES BEACH PHYSICAL REHABILITATION PLLC
Entity Type:Organization
Organization Name:HODGES BEACH PHYSICAL REHABILITATION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:904-223-3330
Mailing Address - Street 1:13947 BEACH BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1200
Mailing Address - Country:US
Mailing Address - Phone:904-223-3330
Mailing Address - Fax:904-223-4560
Practice Address - Street 1:13947 BEACH BLVD STE 202
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1200
Practice Address - Country:US
Practice Address - Phone:904-223-3330
Practice Address - Fax:904-223-4560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8853111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty