Provider Demographics
NPI:1902056948
Name:HENDERSON WELLNESS CENTER, PA
Entity Type:Organization
Organization Name:HENDERSON WELLNESS CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-430-8000
Mailing Address - Street 1:414 DABNEY DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-3944
Mailing Address - Country:US
Mailing Address - Phone:252-430-8000
Mailing Address - Fax:252-430-8200
Practice Address - Street 1:414 DABNEY DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-3944
Practice Address - Country:US
Practice Address - Phone:252-430-8000
Practice Address - Fax:252-430-8200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25053261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8953753Medicaid
208442AMedicare PIN
NC8953753Medicaid