Healthcare Provider Details

I. General information

NPI: 1104988153
Provider Name (Legal Business Name): MARK A. HENDLEY CASE MANAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 4TH AVE
RATON NM
87740-2643
US

IV. Provider business mailing address

136 CANYON DR
RATON NM
87740-3756
US

V. Phone/Fax

Practice location:
  • Phone: 505-445-2754
  • Fax: 505-445-2225
Mailing address:
  • Phone: 505-445-2754
  • Fax: 505-445-2225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: