Healthcare Provider Details

I. General information

NPI: 1790319051
Provider Name (Legal Business Name): WILFER HENDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 GARDEN OAKS DR SW
CAMDEN AR
71701-3733
US

IV. Provider business mailing address

206 GARDEN OAKS DR SW
CAMDEN AR
71701-3733
US

V. Phone/Fax

Practice location:
  • Phone: 870-836-7100
  • Fax:
Mailing address:
  • Phone: 870-836-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number713940
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: