Provider Demographics
NPI:1871780627
Name:KATHY HENDRICKSON, O.D., P.C.
Entity type:Organization
Organization Name:KATHY HENDRICKSON, O.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-652-2020
Mailing Address - Street 1:110 9TH AVE S
Mailing Address - Street 2:P.O. BOX 220
Mailing Address - City:CARRINGTON
Mailing Address - State:ND
Mailing Address - Zip Code:58421-2020
Mailing Address - Country:US
Mailing Address - Phone:701-652-2020
Mailing Address - Fax:
Practice Address - Street 1:110 9TH AVE S
Practice Address - Street 2:
Practice Address - City:CARRINGTON
Practice Address - State:ND
Practice Address - Zip Code:58421-2020
Practice Address - Country:US
Practice Address - Phone:701-652-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND578152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60646Medicaid
ND6058050001Medicare NSC
ND60646Medicaid