Provider Demographics
NPI:1760036032
Name:HENDERSON, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
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 1:5450 E. LAKE MEAD BLVD.
Mailing Address - Street 2:BUILDING D APT. 225
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156
Mailing Address - Country:US
Mailing Address - Phone:702-689-6742
Mailing Address - Fax:
Practice Address - Street 1:5450 E. LAKE MEAD BLVD
Practice Address - Street 2:BUILDING D APT. 225
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89156-0908
Practice Address - Country:US
Practice Address - Phone:702-689-6742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant