Healthcare Provider Details

I. General information

NPI: 1629158449
Provider Name (Legal Business Name): FERNANDO PALENCIA JR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 STURTEVANT ST SUITE 1
SAN DIEGO CA
92136-5069
US

IV. Provider business mailing address

1433 NORMANDY DR
CHULA VISTA CA
91913-3904
US

V. Phone/Fax

Practice location:
  • Phone: 619-556-6671
  • Fax: 619-556-0888
Mailing address:
  • Phone: 323-401-9926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: