Healthcare Provider Details

I. General information

NPI: 1538977012
Provider Name (Legal Business Name): RICHARD JAMES HENDERSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2024
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 19TH ST NE
WATERTOWN SD
57201-3936
US

IV. Provider business mailing address

4 19TH ST NE
WATERTOWN SD
57201-3936
US

V. Phone/Fax

Practice location:
  • Phone: 605-884-2429
  • Fax: 612-725-1099
Mailing address:
  • Phone: 605-884-2429
  • Fax: 612-725-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number13-79536-092
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: