Provider Demographics
NPI:1235299223
Name:PLAZA REHAB AND WELLNESS
Entity Type:Organization
Organization Name:PLAZA REHAB AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:870-572-9003
Mailing Address - Street 1:307 PLAZA
Mailing Address - Street 2:
Mailing Address - City:WEST HELENA
Mailing Address - State:AR
Mailing Address - Zip Code:72390-2453
Mailing Address - Country:US
Mailing Address - Phone:870-572-9003
Mailing Address - Fax:
Practice Address - Street 1:307 PLAZA
Practice Address - Street 2:
Practice Address - City:WEST HELENA
Practice Address - State:AR
Practice Address - Zip Code:72390-2453
Practice Address - Country:US
Practice Address - Phone:870-572-9003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1657111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1657OtherARKANSAS STATE LICENSE
AR5F471OtherBLUE CROSS GROUP ID
AR1657OtherARKANSAS STATE LICENSE
ARV08579Medicare UPIN