Healthcare Provider Details

I. General information

NPI: 1780925180
Provider Name (Legal Business Name): CHARLES A HENDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2013
Last Update Date: 03/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 W CRAIG RD STE A
NORTH LAS VEGAS NV
89032-5116
US

IV. Provider business mailing address

305 NORLEN ST
LAS VEGAS NV
89107-2233
US

V. Phone/Fax

Practice location:
  • Phone: 702-675-6314
  • Fax:
Mailing address:
  • Phone: 801-803-8659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: