MEDICARE: BETTINA LOUISE 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	172A00000X	Driver

General Provider Information

NPI Number	:	1891285607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETTINA LOUISE HENDERSON

Provider Business Mailing Address
First Line	:	111 STOKES RD
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39702-7541
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 STOKES RD
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39702-7541
Country	:	US
Telephone Number	:	662-251-5074
Fax Number	:

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

Provider Enumeration Date	:	05/16/2018
Last Update Date	:	05/16/2018

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Directions to “ BETTINA LOUISE HENDERSON ” Practice Location

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