Healthcare Provider Details

I. General information

NPI: 1578427506
Provider Name (Legal Business Name): EDWIN PENA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17150 VIA DEL CAMPO STE 200
SAN DIEGO CA
92127-2137
US

IV. Provider business mailing address

810 N CEDAR ST
ESCONDIDO CA
92026-3208
US

V. Phone/Fax

Practice location:
  • Phone: 858-381-5084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number309201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: