Provider Demographics
NPI:1073047155
Name:DRH MD MPH A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DRH MD MPH A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-659-8760
Mailing Address - Street 1:8631 W 3RD ST
Mailing Address - Street 2:1135E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5901
Mailing Address - Country:US
Mailing Address - Phone:310-659-8760
Mailing Address - Fax:310-673-0951
Practice Address - Street 1:8631 W 3RD ST
Practice Address - Street 2:1135E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5917
Practice Address - Country:US
Practice Address - Phone:310-659-8760
Practice Address - Fax:310-673-0951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36510174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C365100Medicaid
CA00C365100Medicaid
CAC36510Medicare PIN