Provider Demographics
NPI:1336443159
Name:HODGEWOOD HAVEN LLC
Entity Type:Organization
Organization Name:HODGEWOOD HAVEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THELMA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-312-3736
Mailing Address - Street 1:PO BOX 2421
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-2421
Mailing Address - Country:US
Mailing Address - Phone:606-312-3736
Mailing Address - Fax:
Practice Address - Street 1:85 S LAUREL RD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-8550
Practice Address - Country:US
Practice Address - Phone:606-312-3736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-08
Last Update Date:2011-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPENDING261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care