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General NPI Number Information
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NPI Number | 1396925129
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Entity Type | Organization
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Legal Business Name | DEANGELO HENDERSON
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Dates
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Enumeration Date | 11/08/2007
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Last Update Date | 07/17/2008
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Provider Practice Location Address
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Address Line | 3380 E RUSSELL RD #104
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City | LAS VEGAS
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State | NV
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Zip | 89120-3402
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Country | US
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Telephone | 702-487-6221
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Fax | 702-487-6623
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Provider Business Mailing Address
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Address Line | 3380 E RUSSELL RD #104
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City | LAS VEGAS
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State | NV
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Zip | 89120-3402
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Country | US
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Telephone | 702-487-6221
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Fax | 702-487-6623
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Authorized Official
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Title or Position | OWNER
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Name | DEANGELO D HENDERSON
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Credential |
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Telephone | 702-487-6221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | MP00479
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License Number State | NV
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