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General NPI Number Information
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NPI Number | 1003448770
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Entity Type | Organization
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Legal Business Name | INTERSTATE CLINIC LLC
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Dates
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Enumeration Date | 02/10/2020
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Last Update Date | 08/27/2020
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Provider Practice Location Address
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Address Line | 210 N BOSQUE ST
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City | WHITNEY
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State | TX
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Zip | 76692-2416
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Country | US
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Telephone | 254-221-4342
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Fax | 254-221-7051
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Provider Business Mailing Address
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Address Line | PO BOX 1400
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City | WHITNEY
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State | TX
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Zip | 76692-1400
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Country | US
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Telephone | 254-707-0095
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Fax | 800-257-1471
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Authorized Official
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Title or Position | OWNER
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Name | DR. RANDALL DALE HENDERSON
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Credential | DO
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Telephone | 254-707-0095
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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