Healthcare Provider Details

I. General information

NPI: 1598742694
Provider Name (Legal Business Name): HENDERSON B BRENNER III P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1602
US

IV. Provider business mailing address

950 J CLYDE MORRIS BLVD STE 102
NEWPORT NEWS VA
23601-1004
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7500
  • Fax:
Mailing address:
  • Phone: 469-569-9407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number1109718
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: