Provider Demographics
NPI:1679590699
Name:MISENHEIMER, RANDY GENE (PT)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:GENE
Last Name:MISENHEIMER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7111 BOSQUE BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-4067
Mailing Address - Country:US
Mailing Address - Phone:254-235-0708
Mailing Address - Fax:254-693-7775
Practice Address - Street 1:7111 BOSQUE BLVD
Practice Address - Street 2:STE 101
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4067
Practice Address - Country:US
Practice Address - Phone:254-235-0708
Practice Address - Fax:254-693-7775
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10249172251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic