Provider Demographics
NPI:1528765708
Name:HENDERSON, TEVIN DONTE
Entity type:Individual
Prefix:
First Name:TEVIN
Middle Name:DONTE
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1294
Mailing Address - Street 2:
Mailing Address - City:CROSS CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32628-1294
Mailing Address - Country:US
Mailing Address - Phone:352-210-5731
Mailing Address - Fax:
Practice Address - Street 1:26638 SE HWY 19 STE B
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:FL
Practice Address - Zip Code:32680-8539
Practice Address - Country:US
Practice Address - Phone:352-210-5731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27458-164-935-1042246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty