Provider Demographics
NPI:1942313085
Name:HENDERSON, BEVERLY (DC)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
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:PO BOX 09092
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-0092
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1605885OtherBCBS
ILU11240Medicare UPIN
IL359460Medicare ID - Type UnspecifiedMEDICARE