Healthcare Provider Details

I. General information

NPI: 1003843616
Provider Name (Legal Business Name): VANCE V PENN M.ED, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 431 BOX 2152
APO AE
09175
US

IV. Provider business mailing address

CMR 431 BOX 2152
APO AE
09175
US

V. Phone/Fax

Practice location:
  • Phone: 4916093968204
  • Fax:
Mailing address:
  • Phone: 4916093968204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: