Healthcare Provider Details

I. General information

NPI: 1609770288
Provider Name (Legal Business Name): KEITH T. HENDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 W DOUGLAS AVE
WICHITA KS
67213-2407
US

IV. Provider business mailing address

3457 S EVERETT ST
WICHITA KS
67217-2143
US

V. Phone/Fax

Practice location:
  • Phone: 316-941-9948
  • Fax: 316-943-7195
Mailing address:
  • Phone: 316-350-5841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: