Healthcare Provider Details

I. General information

NPI: 1508937194
Provider Name (Legal Business Name): BEVERLY JEAN PENCEK D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 SHORELINE HWY
PT REYES STATION CA
94956
US

IV. Provider business mailing address

11100 STATE ROUTE 1 PO BOX 236
PT REYES STATION CA
94956
US

V. Phone/Fax

Practice location:
  • Phone: 415-663-8442
  • Fax: 415-663-1842
Mailing address:
  • Phone: 415-663-8442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number26914
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: