Basic Information
| Provider Information | |||||||||
| NPI: | 1043334261 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | BC-HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 E SUNSET RD | ||||||||
| Address2: | UNIT 5-260 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891203511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027980113 | ||||||||
| FaxNumber: | 8662915242 | ||||||||
| Practice Location | |||||||||
| Address1: | 10404 W COGGINS DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SUN CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853513437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239749666 | ||||||||
| FaxNumber: | 6239744813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 07/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 00729 | IA | N | Other Service Providers | Specialist | 237700000X | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0227132 | 05 | IA | MEDICAID | 42150911900 | 05 | NE | MEDICAID | 348031700 | 01 | DOL NUMBER | OTHER |