1275726614 NPI number — THE HENDERSON CLINIC LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275726614 NPI number — THE HENDERSON CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE HENDERSON CLINIC LLC
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:
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:
1275726614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
359 TOWNE CENTER BLVD
Provider Second Line Business Mailing Address:
SUITE 601
Provider Business Mailing Address City Name:
RIDGELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39157-4868
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-572-8686
Provider Business Mailing Address Fax Number:
601-572-8685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
359 TOWNE CENTER BLVD
Provider Second Line Business Practice Location Address:
SUITE 601
Provider Business Practice Location Address City Name:
RIDGELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39157-4868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-572-8686
Provider Business Practice Location Address Fax Number:
601-572-8685
Provider Enumeration Date:
08/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HENDERSON
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
CONNELL
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
601-572-8686

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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