Provider Demographics
NPI:1043968894
Name:HENDERSON STATE UNIVERSITY
Entity Type:Organization
Organization Name:HENDERSON STATE UNIVERSITY
Other - Org Name:STUDENT HEALTH AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:870-230-5102
Mailing Address - Street 1:1100 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71999-0001
Mailing Address - Country:US
Mailing Address - Phone:870-230-5102
Mailing Address - Fax:
Practice Address - Street 1:1100 HENDERSON ST
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71999-0001
Practice Address - Country:US
Practice Address - Phone:870-230-5102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HENDERSON STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-11
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty