Provider Demographics
NPI:1023046497
Name:HENDERSON, KENNETH J (LAT, ATC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 NE 30 RD
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-9251
Mailing Address - Country:US
Mailing Address - Phone:620-792-9371
Mailing Address - Fax:620-786-1161
Practice Address - Street 1:245 NE 30 RD
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-9251
Practice Address - Country:US
Practice Address - Phone:620-792-9371
Practice Address - Fax:620-786-1161
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-000482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSPROVIDER CODE 22OtherREHAB. & RESTORATIVE SERV