Provider Demographics
NPI:1609154921
Name:MCKENNA ORTHOPAEDIC AND SPORTS MEDICINE PA
Entity Type:Organization
Organization Name:MCKENNA ORTHOPAEDIC AND SPORTS MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:940-393-6484
Mailing Address - Street 1:1713 S FM 51
Mailing Address - Street 2:#103
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3642
Mailing Address - Country:US
Mailing Address - Phone:940-627-6976
Mailing Address - Fax:940-687-9035
Practice Address - Street 1:1713 S FM 51
Practice Address - Street 2:#103
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3642
Practice Address - Country:US
Practice Address - Phone:940-627-6976
Practice Address - Fax:940-687-9035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty