1356024533 NPI number — GUADALUPE DEL ROSA CHAVEZ PENA

Table of content: GUADALUPE DEL ROSA CHAVEZ PENA (NPI 1356024533)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356024533 NPI number — GUADALUPE DEL ROSA CHAVEZ PENA

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
PENA

Provider First Name:
GUADALUPE DEL ROSA

Provider Middle Name:
CHAVEZ

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:
1356024533

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
08/22/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3609 W 15TH LN

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
YUMA

Provider Business Mailing Address State Name:
AZ

Provider Business Mailing Address Postal Code:
85364-4155

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
928-975-4295

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AV. REVOLUCION Y CALLE 17 NUM797 COL. RESDIDENCIAS

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
SAN LUIS RIO COLORADO

Provider Business Practice Location Address State Name:
SONORA

Provider Business Practice Location Address Postal Code:
83450

Provider Business Practice Location Address Country Code:
MX

Provider Business Practice Location Address Telephone Number:
653-536-1567

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
08/14/2023

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: 122300000X , with the licence number: 5166749 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .