Healthcare Provider Details

I. General information

NPI: 1144490202
Provider Name (Legal Business Name): MATTHEW LEE PENSE IDEPENDENT DUTY CORP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 RADFORD BLVD
ALBANY GA
31704-9998
US

IV. Provider business mailing address

814 RADFORD BLVD
ALBANY GA
31704-1130
US

V. Phone/Fax

Practice location:
  • Phone: 229-639-7886
  • Fax:
Mailing address:
  • Phone: 229-639-7886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: