NPI |
1154109643 |
Other last name by which the provider being identified is or has been known. |
Entity Type Code |
1 |
Other first name by which the provider being identified is or has been known (if an individual). This may be the same as the ‘‘Provider first name’’ if the provider is or has been known by a different last name only. |
Provider Last Name Legal Name |
HENDERSON |
The other name prefix or salutation of the provider
if the provider is an individual; for example, Mr., Mrs., or Corporal. |
Provider First Name |
LARICC |
The other abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
Provider First Line Business Practice Location Address |
3100 E 45TH ST STE 320 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
Provider Business Practice Location Address City Name |
CLEVELAND |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address State Name |
OH |
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot
include a Post Office box. |
Provider Business Practice Location Address Postal Code |
441271091 |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Telephone Number |
2164171115 |
The telephone number associated with the location address of the provider being identified. |
Provider Enumeration Date |
9/18/2023 |
The country code in the location address of the provider being identified. |
Last Update Date |
9/18/2023 |
The telephone number associated with the location address of the provider being identified. |
Provider Gender Code |
M |
The fax number associated with the location
address of the provider being identified. |
Healthcare Provider Taxonomy Code 1 |
101YM0800X |
The date the provider was assigned a unique identifier (assigned an NPI). |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Sole Proprietor |
Y |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
NPI Certification Date |
9/18/2023 |
|