1225519390 NPI number — CLARA SELENE PENA

Table of content: CLARA SELENE PENA (NPI 1225519390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225519390 NPI number — CLARA SELENE PENA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENA
Provider First Name:
CLARA
Provider Middle Name:
SELENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225519390
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 BUSINESS 83 STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DONNA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78537-3088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-464-2386
Provider Business Mailing Address Fax Number:
956-464-2210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 BUSINESS 83 STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DONNA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78537-3088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-464-2386
Provider Business Practice Location Address Fax Number:
956-464-2210
Provider Enumeration Date:
08/27/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X , with the licence number:  145132 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1083928634 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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