Provider Demographics
NPI:1154591568
Name:HENNICKEN, PAUL J (DC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:HENNICKEN
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 1:68 GLOBAL DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4628
Mailing Address - Country:US
Mailing Address - Phone:864-644-2700
Mailing Address - Fax:864-644-2709
Practice Address - Street 1:1624 WOODRUFF RD STE 8
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5944
Practice Address - Country:US
Practice Address - Phone:864-363-5239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-03
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3322111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3322OtherDC LICENSE