MEDICARE: RODNEY D. HENSON

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
1	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932195195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RODNEY D. HENSON

Provider Business Mailing Address
First Line	:	2540 PACIFIC AVE
Second Line	:	SUITE 2B
City	:	STOCKTON
State	:	CA
Zip	:	95204-4400
Country	:	US
Telephone Number	:	209-944-9990
Fax Number	:	209-944-9992

Provider Business Practice Location Address
First Line	:	2540 PACIFIC AVE
Second Line	:	SUITE 2B
City	:	STOCKTON
State	:	CA
Zip	:	95204-4400
Country	:	US
Telephone Number	:	209-944-9990
Fax Number	:	209-944-9992

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RODNEY DOUGLAS HENSON
Credential	:	CPO 02313
Telephone Number	:	209-944-9990

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	09/08/2015

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