Provider Demographics
NPI:1821291923
Name:W.RAY HENDERSON MD INC
Entity Type:Organization
Organization Name:W.RAY HENDERSON MD INC
Other - Org Name:RENAISSANCE COSMETIC SURGERY
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-346-3810
Mailing Address - Street 1:73180 EL PASEO
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-4218
Mailing Address - Country:US
Mailing Address - Phone:760-346-3810
Mailing Address - Fax:760-346-3083
Practice Address - Street 1:73180 EL PASEO
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-4218
Practice Address - Country:US
Practice Address - Phone:760-346-3810
Practice Address - Fax:760-346-3083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC24144261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA250030001824OtherASC PROVIDER NUMBER
CA250030001824OtherASC PROVIDER NUMBER