1659301372 NPI number — STANLEY P. HENDERSON, D.C., A PROFESSIONAL CORPORATION

Table of content: (NPI 1659301372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659301372 NPI number — STANLEY P. HENDERSON, D.C., A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STANLEY P. HENDERSON, D.C., A PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1659301372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25050 PEACHLAND AVE
Provider Second Line Business Mailing Address:
SUITE 155
Provider Business Mailing Address City Name:
NEWHALL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91321-2523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-254-2090
Provider Business Mailing Address Fax Number:
661-254-5665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25050 PEACHLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 155
Provider Business Practice Location Address City Name:
NEWHALL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91321-2523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-254-2090
Provider Business Practice Location Address Fax Number:
661-254-5665
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENDERSON
Authorized Official First Name:
STANLEY
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
661-254-2090

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC13794 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DC013794 . This is a "BLUE SHIELD ID#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: W21449 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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