Provider Demographics
NPI:1639571201
Name:HENDERSON STATE UNIVERSITY
Entity Type:Organization
Organization Name:HENDERSON STATE UNIVERSITY
Other - Org Name:HENDERSON STATE SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST. ATHLETICS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROB
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-230-5069
Mailing Address - Street 1:5050 SPRING VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-3995
Mailing Address - Country:US
Mailing Address - Phone:800-555-9073
Mailing Address - Fax:972-367-3452
Practice Address - Street 1:1100 HENDERSON ST
Practice Address - Street 2:HSU BOX 7630
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71999-0001
Practice Address - Country:US
Practice Address - Phone:870-230-5426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty