Provider Demographics
NPI:1083000624
Name:TIMOTHY JAMES HENDESON
Entity Type:Organization
Organization Name:TIMOTHY JAMES HENDESON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-430-0382
Mailing Address - Street 1:610 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-2902
Mailing Address - Country:US
Mailing Address - Phone:605-342-3908
Mailing Address - Fax:605-342-0250
Practice Address - Street 1:610 EAST BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2902
Practice Address - Country:US
Practice Address - Phone:605-342-3908
Practice Address - Fax:605-342-0250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1055111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7602532Medicaid
SD7602532Medicaid
100397Medicare PIN