Provider Demographics
NPI:1306041124
Name:HENDERSON, GARY (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FITNESS DR
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-9584
Mailing Address - Country:US
Mailing Address - Phone:815-929-2190
Mailing Address - Fax:815-929-2191
Practice Address - Street 1:100 FITNESS DR
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-9584
Practice Address - Country:US
Practice Address - Phone:815-929-2190
Practice Address - Fax:815-929-2191
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor