Provider Demographics
NPI:1730519711
Name:WILBORN, HENDERSON II
Entity type:Individual
Prefix:MR
First Name:HENDERSON
Middle Name:
Last Name:WILBORN
Suffix:II
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 3479
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38173
Mailing Address - Country:US
Mailing Address - Phone:901-808-3279
Mailing Address - Fax:901-671-1121
Practice Address - Street 1:4466 ELVIS PRESLEY BLVD
Practice Address - Street 2:SUITE 115
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116
Practice Address - Country:US
Practice Address - Phone:907-808-3279
Practice Address - Fax:901-671-1121
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44D2067576247000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN264040069Medicaid