Provider Demographics
NPI:1306275060
Name:HODGE, IBERIA
Entity type:Individual
Prefix:MRS
First Name:IBERIA
Middle Name:
Last Name:HODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:IBERIA
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6209 SILVER VEIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-1198
Mailing Address - Country:US
Mailing Address - Phone:702-331-4115
Mailing Address - Fax:
Practice Address - Street 1:3674 N RANCHO DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3110
Practice Address - Country:US
Practice Address - Phone:702-396-2988
Practice Address - Fax:510-281-6883
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV26-3823222OtherFEDERAL TAX ID