Provider Demographics
NPI:1124264114
Name:LORETTA V HENDERSON DPM
Entity type:Organization
Organization Name:LORETTA V HENDERSON DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:V
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:866-365-3668
Mailing Address - Street 1:PO BOX 720849
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32872-0849
Mailing Address - Country:US
Mailing Address - Phone:866-365-3668
Mailing Address - Fax:407-870-7753
Practice Address - Street 1:1543 ALDERSGATE DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-6545
Practice Address - Country:US
Practice Address - Phone:866-365-3668
Practice Address - Fax:407-870-7753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1685332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0704290001Medicare NSC