MEDICARE: AGUSTIN PENA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner
2	106S00000X	Behavior Technician	RBT-17-41330	NV

General Provider Information

NPI Number	:	1013356906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGUSTIN PENA

Provider Business Mailing Address
First Line	:	2301 CEDAR AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-3401
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2301 CEDAR AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-3401
Country	:	US
Telephone Number	:	702-287-2501
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2013
Last Update Date	:	03/02/2018

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Directions to “ AGUSTIN PENA ” Practice Location

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