Healthcare Provider Details

I. General information

NPI: 1821874470
Provider Name (Legal Business Name): PAUL KEITH HENDERSON CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LORD EFFINGHAM DR
RINCON GA
31326-5017
US

IV. Provider business mailing address

101 LORD EFFINGHAM DR
RINCON GA
31326-5017
US

V. Phone/Fax

Practice location:
  • Phone: 912-656-1908
  • Fax:
Mailing address:
  • Phone: 912-656-1908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: