Provider Demographics
NPI:1144699646
Name:HENDRICKS, RAYMOND B
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:B
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 ANNETTE ST
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33980
Mailing Address - Country:US
Mailing Address - Phone:941-764-1572
Mailing Address - Fax:
Practice Address - Street 1:1306 ANNETTE ST
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980
Practice Address - Country:US
Practice Address - Phone:941-764-1572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906749311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home