1043334261 NPI number — MR. RANDALL WAYNE HENDERSON BC-HIS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043334261 NPI number — MR. RANDALL WAYNE HENDERSON BC-HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
RANDALL
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BC-HIS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043334261
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2510 E SUNSET RD
Provider Second Line Business Mailing Address:
UNIT 5-260
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89120-3511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-798-0113
Provider Business Mailing Address Fax Number:
866-291-5242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10404 W COGGINS DR
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
SUN CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85351-3437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-974-9666
Provider Business Practice Location Address Fax Number:
623-974-4813
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  00729 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0227132 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42150911900 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 348031700 . This is a "DOL NUMBER" identifier . This identifiers is of the category "OTHER".




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