Provider Demographics
NPI:1689740771
Name:HENDERSON, LAUREN J (MNT)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:J
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2617
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-4617
Mailing Address - Country:US
Mailing Address - Phone:803-328-2401
Mailing Address - Fax:803-328-1030
Practice Address - Street 1:1721 EBENEZER RD
Practice Address - Street 2:SUITE 145
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-4103
Practice Address - Country:US
Practice Address - Phone:803-328-2401
Practice Address - Fax:803-328-1030
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13597133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ50327Medicare UPIN
SCQ503271467Medicare PIN