Provider Demographics
NPI:1316048697
Name:HENDERSON, KIRK BROOKS (DC)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:BROOKS
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 1:519 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:SD
Mailing Address - Zip Code:57013-1206
Mailing Address - Country:US
Mailing Address - Phone:605-214-5804
Mailing Address - Fax:
Practice Address - Street 1:113 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:SD
Practice Address - Zip Code:57013-2224
Practice Address - Country:US
Practice Address - Phone:052-145-8046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1087111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7605300Medicaid