Provider Demographics
NPI:1013439736
Name:HOLISTIC FAMILY HEALTH BY HODGE
Entity Type:Organization
Organization Name:HOLISTIC FAMILY HEALTH BY HODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HODGE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:662-420-3264
Mailing Address - Street 1:3129 PINETREE LOOP S
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-9520
Mailing Address - Country:US
Mailing Address - Phone:662-420-3264
Mailing Address - Fax:
Practice Address - Street 1:5699 GETWELL RD STE 3
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-7312
Practice Address - Country:US
Practice Address - Phone:662-420-3264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR858633261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care