| Doctor Name: | ROY RANDEL HENNEBERG |
| NPI Number: | 1114956216 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MD |
| License Number: | M4722 |
| Business Practice Address: | 980 W Ironwood Dr Suite 304 Coeur D Alene, ID - 83814 |
| Business Phone Number: | 2087654888 |
| Business Fax Number: | 2086678618 |
| Mailing Address: | 980 W Ironwood Dr, Suite 304 COEUR D ALENE |
| State: | ID |
| Postal Code: | 83814 |
| Phone Number: | 2087654888 |
| Fax Number: | 2086678618 |
| NPI Enumeration Date: | 07/01/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | M4722 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |