Healthcare Provider Details

I. General information

NPI: 1659541191
Provider Name (Legal Business Name): KENNETH ALLEN HENDRICKS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 819 BOX 18
FPO AE
09645-0018
US

IV. Provider business mailing address

PSC 819 BOX 18
FPO AE
09645-0018
US

V. Phone/Fax

Practice location:
  • Phone: 314-727-3524
  • Fax: 314-727-3166
Mailing address:
  • Phone: 314-727-3524
  • Fax: 314-727-3166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102202300
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: