1578244612 NPI number — DR. MICHAEL CARL HENDRICKSON DPT

Table of content: (NPI 1124435540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578244612 NPI number — DR. MICHAEL CARL HENDRICKSON DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKSON
Provider First Name:
MICHAEL
Provider Middle Name:
CARL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578244612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16560 WEDGE PKWY # 200A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89511-3318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-384-1400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4878 SPARKS BLVD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARKS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89436-8150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-507-4084
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5171 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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