Provider Demographics
NPI:1942397377
Name:HENDERSON CHIROPRACTIC & SPORTS REHAB, P.C.
Entity type:Organization
Organization Name:HENDERSON CHIROPRACTIC & SPORTS REHAB, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:TRIPP
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:662-236-2295
Mailing Address - Street 1:1211 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-9330
Mailing Address - Country:US
Mailing Address - Phone:662-236-2295
Mailing Address - Fax:662-236-2215
Practice Address - Street 1:1211 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-9330
Practice Address - Country:US
Practice Address - Phone:662-236-2295
Practice Address - Fax:662-236-2215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1007111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015806Medicaid
MSC03184Medicare ID - Type UnspecifiedGROUP NUMBER