Healthcare Provider Details

I. General information

NPI: 1245819721
Provider Name (Legal Business Name): MEDICINE BY DR HENDERSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2021
Last Update Date: 11/25/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 N MAIN ST
BUTLER MO
64730-2135
US

IV. Provider business mailing address

PO BOX 28
BUTLER MO
64730-2135
US

V. Phone/Fax

Practice location:
  • Phone: 660-386-7008
  • Fax: 660-386-7009
Mailing address:
  • Phone: 660-386-7008
  • Fax: 660-386-7009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GAYLE STARK
Title or Position: CREDENTIALING OFFICER
Credential:
Phone: 660-424-0794