Provider Demographics
NPI:1144062530
Name:HENDERSON, GEORGE CLEVELAND JR
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:CLEVELAND
Last Name:HENDERSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:GEORGE
Other - Middle Name:CLEVELAND
Other - Last Name:HENDERSON
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:CKM
Mailing Address - Street 1:900 G ST NE APT 502
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-7414
Mailing Address - Country:US
Mailing Address - Phone:856-895-1535
Mailing Address - Fax:
Practice Address - Street 1:900 G ST NE APT 502
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-7414
Practice Address - Country:US
Practice Address - Phone:856-895-1535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCFS-103770332U00000X, 174200000X
374K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174200000XOther Service ProvidersMeals
No332U00000XSuppliersHome Delivered Meals
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner