Provider Demographics
NPI:1659301372
Name:STANLEY P. HENDERSON, D.C., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:STANLEY P. HENDERSON, D.C., A PROFESSIONAL CORPORATION
Other - Org Name:WHITE LIGHT CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:661-254-2090
Mailing Address - Street 1:25050 PEACHLAND AVE
Mailing Address - Street 2:SUITE 155
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2523
Mailing Address - Country:US
Mailing Address - Phone:661-254-2090
Mailing Address - Fax:661-254-5665
Practice Address - Street 1:25050 PEACHLAND AVE
Practice Address - Street 2:SUITE 155
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2523
Practice Address - Country:US
Practice Address - Phone:661-254-2090
Practice Address - Fax:661-254-5665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC13794111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC013794OtherBLUE SHIELD ID#
CAW21449OtherMEDICARE PTAN
CADC13794Medicare PIN