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General NPI Number Information
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NPI Number | 1225186398
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Entity Type | Individual
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Provider Name | LANCE HENDERSON
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Gender | Male
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Dates
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Enumeration Date | 01/08/2007
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Last Update Date | 04/15/2009
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Provider Practice Location Address
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Address Line | 134 N STATE ST
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City | PRESTON
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State | ID
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Zip | 83263-1143
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Country | US
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Telephone | 208-852-3030
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Fax |
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Provider Business Mailing Address
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Address Line | 749 NORTH 4900 WEST P.O. BOX 143
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City | DAYTON
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State | ID
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Zip | 83232
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Country | US
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Telephone | 208-747-3020
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | ODP-1004
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License Number State | ID
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