Healthcare Provider Details

I. General information

NPI: 1922981737
Provider Name (Legal Business Name): ANGEL DE LA PENA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49211 GRAPEFRUIT BLVD STE 5
COACHELLA CA
92236-1480
US

IV. Provider business mailing address

78730 ROCKBERRY CT
LA QUINTA CA
92253-4186
US

V. Phone/Fax

Practice location:
  • Phone: 760-541-8520
  • Fax:
Mailing address:
  • Phone: 760-540-6837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: