Healthcare Provider Details

I. General information

NPI: 1730519711
Provider Name (Legal Business Name): MR. HENDERSON WILBORN II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4466 ELVIS PRESLEY BLVD SUITE 115
MEMPHIS TN
38116
US

IV. Provider business mailing address

PO BOX 3479
MEMPHIS TN
38173
US

V. Phone/Fax

Practice location:
  • Phone: 907-808-3279
  • Fax: 901-671-1121
Mailing address:
  • Phone: 901-808-3279
  • Fax: 901-671-1121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number44D2067576
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: