MEDICARE: WILFER 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	2251S0007X	Sports Physical Therapist	713940	AR

General Provider Information

NPI Number	:	1790319051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILFER HENDERSON

Provider Business Mailing Address
First Line	:	206 GARDEN OAKS DR SW
Second Line	:
City	:	CAMDEN
State	:	AR
Zip	:	71701-3733
Country	:	US
Telephone Number	:	870-836-7100
Fax Number	:

Provider Business Practice Location Address
First Line	:	206 GARDEN OAKS DR SW
Second Line	:
City	:	CAMDEN
State	:	AR
Zip	:	71701-3733
Country	:	US
Telephone Number	:	870-836-7100
Fax Number	:

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

Provider Enumeration Date	:	02/26/2020
Last Update Date	:	02/26/2020

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Directions to “ WILFER HENDERSON ” Practice Location

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