Healthcare Provider Details

I. General information

NPI: 1114931052
Provider Name (Legal Business Name): DE LA PENA EYE CLINIC, A MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2446 W WHITTIER BLVD
MONTEBELLO CA
90640-3041
US

IV. Provider business mailing address

401 COMMERCE ST STE 600
NASHVILLE TN
37219-2518
US

V. Phone/Fax

Practice location:
  • Phone: 323-728-5500
  • Fax: 323-728-4408
Mailing address:
  • Phone: 615-345-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK KELLY
Title or Position: MEMBER, BOARD OF MANAGERS
Credential:
Phone: 615-345-6900