MEDICARE: DEANGELO HENDERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	MP00479	NV

General Provider Information

NPI Number	:	1396925129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEANGELO HENDERSON

Provider Business Mailing Address
First Line	:	3380 E RUSSELL RD #104
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-3402
Country	:	US
Telephone Number	:	702-487-6221
Fax Number	:	702-487-6623

Provider Business Practice Location Address
First Line	:	3380 E RUSSELL RD #104
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-3402
Country	:	US
Telephone Number	:	702-487-6221
Fax Number	:	702-487-6623

Authorized Official
Title or Position	:	OWNER
Name	:	DEANGELO D HENDERSON
Credential	:
Telephone Number	:	702-487-6221

Provider Enumeration Date	:	11/08/2007
Last Update Date	:	07/17/2008

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