Basic Information
| Provider Information | |||||||||
| NPI: | 1740675677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | RALPH | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2416 HIGHWAY 45 N | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397051320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623276705 | ||||||||
| FaxNumber: | 6623276760 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 N WALMART DR | ||||||||
| Address2: | SUITE F | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393395905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627791096 | ||||||||
| FaxNumber: | 6627793949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2015 | ||||||||
| LastUpdateDate: | 01/26/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT4021 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.