1205804507 NPI number — MR. WEBSTER T HENDRICKS BS, CAC III

Table of content: MR. WEBSTER T HENDRICKS BS, CAC III (NPI 1205804507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205804507 NPI number — MR. WEBSTER T HENDRICKS BS, CAC III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKS
Provider First Name:
WEBSTER
Provider Middle Name:
T
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BS, CAC III
Provider Gender Code:
M

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:
1205804507
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15072 E 50TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80239-4272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-371-4908
Provider Business Mailing Address Fax Number:
303-574-0187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15072 E 50TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80239-4272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-371-4908
Provider Business Practice Location Address Fax Number:
303-574-0187
Provider Enumeration Date:
03/10/2006

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: 101YA0400X , with the licence number:  CAC III - #690 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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