Provider Demographics
NPI:1043334261
Name:HENDERSON, RANDALL WAYNE (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:WAYNE
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 E SUNSET RD
Mailing Address - Street 2:UNIT 5-260
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3511
Mailing Address - Country:US
Mailing Address - Phone:702-798-0113
Mailing Address - Fax:866-291-5242
Practice Address - Street 1:10404 W COGGINS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3437
Practice Address - Country:US
Practice Address - Phone:623-974-9666
Practice Address - Fax:623-974-4813
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00729174400000X
237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0227132Medicaid
NE42150911900Medicaid
348031700OtherDOL NUMBER