Provider Demographics
NPI:1790977841
Name:BEVERLY HENDERSON LTD P.C
Entity Type:Organization
Organization Name:BEVERLY HENDERSON LTD P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-791-0453
Mailing Address - Street 1:2807 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-5617
Mailing Address - Country:US
Mailing Address - Phone:312-791-0453
Mailing Address - Fax:312-791-0715
Practice Address - Street 1:2807 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-5617
Practice Address - Country:US
Practice Address - Phone:312-791-0453
Practice Address - Fax:312-791-0715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1605885OtherBCBS
ILU11240Medicare UPIN
IL1605885OtherBCBS