Provider Demographics
NPI:1447954979
Name:HENDERSON, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 PRINCETON CT
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-7761
Mailing Address - Country:US
Mailing Address - Phone:916-878-0311
Mailing Address - Fax:
Practice Address - Street 1:356 PRINCETON CT
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7761
Practice Address - Country:US
Practice Address - Phone:916-878-0311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25547332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies