1023092822 NPI number — MARGOT D HENDERSON P.A.-C.

Table of content: MARGOT D HENDERSON P.A.-C. (NPI 1023092822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023092822 NPI number — MARGOT D HENDERSON P.A.-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
MARGOT
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023092822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3900 STOCKTON HILL RD STE B368
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGMAN
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86409-3029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-681-1234
Provider Business Mailing Address Fax Number:
928-681-1811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1755 AIRWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGMAN
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86409-3620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-681-1234
Provider Business Practice Location Address Fax Number:
928-681-1811
Provider Enumeration Date:
12/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  2798 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 827149 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00256908 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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