Healthcare Provider Details

I. General information

NPI: 1205916004
Provider Name (Legal Business Name): HALLIE HENDERSON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7855 MOFFETT RD
SEMMES AL
36575-5411
US

IV. Provider business mailing address

293 MOODY RD
LUCEDALE MS
39452-8778
US

V. Phone/Fax

Practice location:
  • Phone: 251-649-7752
  • Fax:
Mailing address:
  • Phone: 601-947-3250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberR-149 TA-684
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: