MEDICARE: TEVIN DONTE HENDERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246RP1900X	Phlebotomy Technician	27458-164-935-1042	FL

General Provider Information

NPI Number	:	1528765708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEVIN DONTE HENDERSON

Provider Business Mailing Address
First Line	:	PO BOX 1294
Second Line	:
City	:	CROSS CITY
State	:	FL
Zip	:	32628-1294
Country	:	US
Telephone Number	:	352-210-5731
Fax Number	:

Provider Business Practice Location Address
First Line	:	26638 SE HWY 19 STE B
Second Line	:
City	:	OLD TOWN
State	:	FL
Zip	:	32680-8539
Country	:	US
Telephone Number	:	352-210-5731
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2023
Last Update Date	:	02/08/2023

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Directions to “ TEVIN DONTE HENDERSON ” Practice Location

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