Provider Demographics
NPI:1366862310
Name:RANDALL HENDERSON, D.O. PLLC
Entity Type:Organization
Organization Name:RANDALL HENDERSON, D.O. PLLC
Other - Org Name:WHITNEY FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:254-694-3621
Mailing Address - Street 1:PO BOX 2177
Mailing Address - Street 2:
Mailing Address - City:WHITNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76692-5177
Mailing Address - Country:US
Mailing Address - Phone:254-694-3621
Mailing Address - Fax:254-694-7436
Practice Address - Street 1:1314 N BRAZOS ST
Practice Address - Street 2:
Practice Address - City:WHITNEY
Practice Address - State:TX
Practice Address - Zip Code:76692-2010
Practice Address - Country:US
Practice Address - Phone:254-694-3621
Practice Address - Fax:254-694-7436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-17
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty