Healthcare Provider Details

I. General information

NPI: 1770558249
Provider Name (Legal Business Name): KATHY MARIE HENDRICKSON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 12/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 9TH AVE S
CARRINGTON ND
58421-2020
US

IV. Provider business mailing address

110 9TH AVE S
CARRINGTON ND
58421-2020
US

V. Phone/Fax

Practice location:
  • Phone: 701-652-2020
  • Fax: 701-652-2942
Mailing address:
  • Phone: 701-652-2020
  • Fax: 701-652-2942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number578
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: