Healthcare Provider Details

I. General information

NPI: 1770133381
Provider Name (Legal Business Name): MATTHEW J PENQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 TRAPELO RD # 2
BELMONT MA
02478-1417
US

IV. Provider business mailing address

107 COLLEGE RD
CONCORD MA
01742-1526
US

V. Phone/Fax

Practice location:
  • Phone: 617-932-1027
  • Fax: 617-932-1476
Mailing address:
  • Phone: 617-932-1027
  • Fax: 617-932-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number24298
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: