Healthcare Provider Details

I. General information

NPI: 1861305294
Provider Name (Legal Business Name): MICHAEL HENDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 N BREED ST
LOS ANGELES CA
90033-2903
US

IV. Provider business mailing address

669 S BURLINGTON AVE
LOS ANGELES CA
90057-3743
US

V. Phone/Fax

Practice location:
  • Phone: 310-466-0433
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: