Provider Demographics
NPI:1053919233
Name:HENDRICKS, MYRON (PROVIDER)
Entity type:Individual
Prefix:
First Name:MYRON
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6753 RUTHERFORD ST # 1B
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-3756
Mailing Address - Country:US
Mailing Address - Phone:313-221-4761
Mailing Address - Fax:
Practice Address - Street 1:3200 GREENFIELD RD STE 300
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1805
Practice Address - Country:US
Practice Address - Phone:313-427-4161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-11
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide