Provider Demographics
NPI:1922305267
Name:HENLEY, SAMUEL THOMAS (DC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:THOMAS
Last Name:HENLEY
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 1:2804 FORUM BLVD
Mailing Address - Street 2:STE 1A
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6322
Mailing Address - Country:US
Mailing Address - Phone:573-356-1876
Mailing Address - Fax:
Practice Address - Street 1:2804 FORUM BLVD STE 1A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6322
Practice Address - Country:US
Practice Address - Phone:573-446-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011005133111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor