Healthcare Provider Details

I. General information

NPI: 1154838753
Provider Name (Legal Business Name): ERIC CHRISTOPHER PENA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6221 NW 36TH ST
VIRGINIA GARDENS FL
33166-7026
US

IV. Provider business mailing address

6221 NW 36TH ST
VIRGINIA GARDENS FL
33166-7026
US

V. Phone/Fax

Practice location:
  • Phone: 305-871-3627
  • Fax: 305-871-4153
Mailing address:
  • Phone: 305-871-3627
  • Fax: 305-871-4153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT33219
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: