Basic Information
| Provider Information | |||||||||
| NPI: | 1740518091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | JOHN NELSON | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 NEWPORT CENTER DR | ||||||||
| Address2: | #213 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926607501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496441322 | ||||||||
| FaxNumber: | 9496440316 | ||||||||
| Practice Location | |||||||||
| Address1: | 26302 LA PAZ RD | ||||||||
| Address2: | STE 105 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926915313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492061700 | ||||||||
| FaxNumber: | 9492061800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2009 | ||||||||
| LastUpdateDate: | 05/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 36249 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.