Healthcare Provider Details

I. General information

NPI: 1558540526
Provider Name (Legal Business Name): PENNY R. VANDESTREEK DO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PLAZA DR ATT NUCLEAR MEDICINE
ROSEVILLE CA
95661-3037
US

IV. Provider business mailing address

PO BOX 1328
ROCKLIN CA
95677-7328
US

V. Phone/Fax

Practice location:
  • Phone: 916-781-1292
  • Fax: 916-663-9912
Mailing address:
  • Phone: 916-781-1292
  • Fax: 916-663-9912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number20A6232
License Number StateCA

VIII. Authorized Official

Name: PENNY R VANDESTREEK
Title or Position: PRESIDENT
Credential: DO
Phone: 916-781-1292