1720070477 NPI number — MR. KEVIN DUANE HENDERSON DC

Table of content: MR. KEVIN DUANE HENDERSON DC (NPI 1720070477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720070477 NPI number — MR. KEVIN DUANE HENDERSON DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
KEVIN
Provider Middle Name:
DUANE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1720070477
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2040 6TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98403-1045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-572-1881
Provider Business Mailing Address Fax Number:
253-572-5682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2040 6TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98403-1045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-572-1881
Provider Business Practice Location Address Fax Number:
253-572-5682
Provider Enumeration Date:
08/18/2005

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: 111N00000X , with the licence number:  025202 CHOOOO2023 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2028538 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 911471138 . This is a "PREMERA BLUE CROSS SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: HE3793 . This is a "REGENCE RIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: KH1021774 . This is a "ASH NETQORK" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 911471138 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 911471138 . This is a "CIGNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0070405 . This is a "WORKERS COMP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 873745 . This is a "FIRST CHOICE HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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