Provider Demographics
NPI:1306604434
Name:HENDERSHOT FOOT & ANKLE CLINIC, LLC
Entity type:Organization
Organization Name:HENDERSHOT FOOT & ANKLE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAIR
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSHOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-669-3676
Mailing Address - Street 1:3650 S EASTERN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-3345
Mailing Address - Country:US
Mailing Address - Phone:702-384-2544
Mailing Address - Fax:702-384-8528
Practice Address - Street 1:3650 S EASTERN AVE STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-3345
Practice Address - Country:US
Practice Address - Phone:702-384-2544
Practice Address - Fax:702-384-8528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-12
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery