Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CH 8692 | FL |
NPI | 1285741744 |
---|---|
Provider Name | Dr. Richard Alva Henry |
First Address | Lauderhill, FL 33351 |
Second Address | Lauderhill, FL 33351-4513 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2006 |
Last Update Date | 16/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
381791100 | (05) | FL |
89496 | BCBS FL (01) | FL |