1922420512 NPI number — JESUS RICARDO PENA RN, BSN, CLT

Table of content: JESUS RICARDO PENA RN, BSN, CLT (NPI 1922420512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922420512 NPI number — JESUS RICARDO PENA RN, BSN, CLT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENA
Provider First Name:
JESUS
Provider Middle Name:
RICARDO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, BSN, CLT
Provider Gender Code:
M

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:
1922420512
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1516 CYNTHIA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINBURG
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78539-5442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-457-3247
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1516 CYNTHIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDINBURG
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78539-5442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-457-3247
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/15/2014

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: 163W00000X , with the licence number:  713779 , 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)





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