Provider Demographics
NPI:1093019846
Name:HENDERSON, KEILAND MAURICE
Entity Type:Individual
Prefix:MR
First Name:KEILAND
Middle Name:MAURICE
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KEILAND
Other - Middle Name:
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:350 KRESGE LN.
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431
Mailing Address - Country:US
Mailing Address - Phone:775-359-9200
Mailing Address - Fax:
Practice Address - Street 1:151 W CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5306
Practice Address - Country:US
Practice Address - Phone:916-470-8628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator