Healthcare Provider Details

I. General information

NPI: 1043334261
Provider Name (Legal Business Name): RANDALL WAYNE HENDERSON BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10404 W COGGINS DR SUITE 110
SUN CITY AZ
85351-3437
US

IV. Provider business mailing address

2510 E SUNSET RD UNIT 5-260
LAS VEGAS NV
89120-3511
US

V. Phone/Fax

Practice location:
  • Phone: 623-974-9666
  • Fax: 623-974-4813
Mailing address:
  • Phone: 702-798-0113
  • Fax: 866-291-5242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number00729
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: