Provider Demographics
NPI:1932195195
Name:RODNEY D. HENSON
Entity Type:Organization
Organization Name:RODNEY D. HENSON
Other - Org Name:HENSON ORTHOTIC & PROSTHETIC ENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:HENSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO 02313
Authorized Official - Phone:209-944-9990
Mailing Address - Street 1:2540 PACIFIC AVE
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-4400
Mailing Address - Country:US
Mailing Address - Phone:209-944-9990
Mailing Address - Fax:209-944-9992
Practice Address - Street 1:2540 PACIFIC AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-4400
Practice Address - Country:US
Practice Address - Phone:209-944-9990
Practice Address - Fax:209-944-9992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0023130Medicaid
CAXC0023130Medicaid
CA5443980001Medicare PIN