Provider Demographics
NPI:1417135302
Name:HENDERSON, SPENCER DEAN (DC)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:DEAN
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 1:1390 S MAPLE GROVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709
Mailing Address - Country:US
Mailing Address - Phone:208-672-0100
Mailing Address - Fax:208-672-0200
Practice Address - Street 1:1390 S MAPLE GROVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-672-0100
Practice Address - Fax:208-672-0200
Is Sole Proprietor?:No
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1288111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor