Healthcare Provider Details

I. General information

NPI: 1871779090
Provider Name (Legal Business Name): RANDALL D HENDERSON DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 E JEFFERSON AVE
WHITNEY TX
76692-2398
US

IV. Provider business mailing address

202 E JEFFERSON AVE
WHITNEY TX
76692-2398
US

V. Phone/Fax

Practice location:
  • Phone: 254-694-2221
  • Fax: 254-694-9978
Mailing address:
  • Phone: 254-694-2221
  • Fax: 254-694-9978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL1340
License Number StateTX

VIII. Authorized Official

Name: MRS. LINDA J HALL
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 254-694-2221