Individual
ROY RANDEL HENNEBERG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
980 W IRONWOOD DR, SUITE 304, COEUR D ALENE, ID 83814
(208) 765-4888
(208) 667-8618
Mailing address
980 W IRONWOOD DR STE 201, COEUR D ALENE, ID 83814-2668
(208) 765-4888
(208) 667-8618
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
M4722
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
001684500
—
ID
Enumeration date
07/01/2006
Last updated
05/14/2020
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