Provider Demographics
NPI:1215130430
Name:HENDERSON, KEITH II
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:HENDERSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2127 E 99TH PL
Mailing Address - Street 2:#193
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-3152
Mailing Address - Country:US
Mailing Address - Phone:323-220-9356
Mailing Address - Fax:323-933-5973
Practice Address - Street 1:5115 W ADAMS BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-2727
Practice Address - Country:US
Practice Address - Phone:323-933-3439
Practice Address - Fax:323-933-5973
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5845171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5845OtherCAS REGISTRATION