Provider Demographics
NPI:1730738444
Name:HODGENVILLE CLINIC
Entity type:Organization
Organization Name:HODGENVILLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-358-3829
Mailing Address - Street 1:207 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:HODGENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42748-1559
Mailing Address - Country:US
Mailing Address - Phone:270-358-3829
Mailing Address - Fax:270-358-9350
Practice Address - Street 1:207 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:HODGENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42748-1559
Practice Address - Country:US
Practice Address - Phone:270-358-3829
Practice Address - Fax:270-358-9350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-05
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64060908Medicaid