Provider Demographics
NPI:1447335153
Name:HENDERSON, ALLEN RANDOLPH (DC)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:RANDOLPH
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-4505
Mailing Address - Country:US
Mailing Address - Phone:334-872-4470
Mailing Address - Fax:334-872-4471
Practice Address - Street 1:611 BROAD ST
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-4505
Practice Address - Country:US
Practice Address - Phone:334-872-4470
Practice Address - Fax:334-872-4471
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1576111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000007904Medicare ID - Type Unspecified
U52253Medicare UPIN