Provider Demographics
NPI:1780934299
Name:HODGES, KEYON LAMAR
Entity type:Individual
Prefix:
First Name:KEYON
Middle Name:LAMAR
Last Name:HODGES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 SE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BELLE GLADE
Mailing Address - State:FL
Mailing Address - Zip Code:33430
Mailing Address - Country:US
Mailing Address - Phone:617-710-3158
Mailing Address - Fax:
Practice Address - Street 1:636 SOUTHEAST 1ST
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430
Practice Address - Country:US
Practice Address - Phone:617-710-3158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL201253779172A00000X
FLRPT36741183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3416L0300XOtherLAND TRANSPORT MEDICAL COURIER