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NPI Code Detail

MEDICARE: RANDALL HENDERSON, D.O. PLLC

MEDICARE: RANDALL HENDERSON, D.O. PLLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine PhysicianL1340TX

General Provider Information

NPI Number : 1366862310
Entity Type Code : Organization
Provider Name (Legal Business Name) : RANDALL HENDERSON, D.O. PLLC
Provider Business Mailing Address
First Line : PO BOX 2177
Second Line :
City : WHITNEY
State : TX
Zip : 76692-5177
Country : US
Telephone Number : 254-694-3621
Fax Number : 254-694-7436
Provider Business Practice Location Address
First Line : 1314 N BRAZOS ST
Second Line :
City : WHITNEY
State : TX
Zip : 76692-2010
Country : US
Telephone Number : 254-694-3621
Fax Number : 254-694-7436
Authorized Official
Title or Position : MANAGING MEMBER
Name : DR. RANDALL DALE HENDERSON
Credential : D.O.
Telephone Number : 254-694-3621
Provider Enumeration Date : 04/17/2014
Last Update Date : 04/24/2014

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