Basic Information
| Provider Information | |||||||||
| NPI: | 1427626712 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | HODO | ||||||||
| FirstName: | BRODERICK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 AVIGNON DR | ||||||||
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| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391575120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016056777 | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 FOX CHASE DR | ||||||||
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| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394022575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013661081 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2021 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT7102 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.