Provider Demographics
NPI:1205373917
Name:HENDERSON, NICARRO
Entity Type:Individual
Prefix:
First Name:NICARRO
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 E DAWSON RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707
Mailing Address - Country:US
Mailing Address - Phone:229-809-7246
Mailing Address - Fax:
Practice Address - Street 1:2005 E DAWSON RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707
Practice Address - Country:US
Practice Address - Phone:229-809-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO102526332B00000X, 174400000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty