Provider Demographics
NPI:1720070477
Name:HENDERSON, KEVIN DUANE (DC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DUANE
Last Name:HENDERSON
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 1:2040 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98403-1045
Mailing Address - Country:US
Mailing Address - Phone:253-572-1881
Mailing Address - Fax:253-572-5682
Practice Address - Street 1:2040 6TH AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98403-1045
Practice Address - Country:US
Practice Address - Phone:253-572-1881
Practice Address - Fax:253-572-5682
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025202 CHOOOO2023111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2028538Medicaid
WA911471138OtherPREMERA BLUE CROSS SHIELD
WAHE3793OtherREGENCE RIDER NUMBER
WAKH1021774OtherASH NETQORK
WA911471138OtherAETNA
WA911471138OtherCIGNA
WA0070405OtherWORKERS COMP
WA873745OtherFIRST CHOICE HEALTH
WA873745OtherFIRST CHOICE HEALTH