Healthcare Provider Details

I. General information

NPI: 1306899489
Provider Name (Legal Business Name): ROGER M. PENNA D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2670 CRIMSON CANYON DR STE 150
LAS VEGAS NV
89128-0848
US

IV. Provider business mailing address

2590 NATURE PARK DR STE 135
NORTH LAS VEGAS NV
89084-3187
US

V. Phone/Fax

Practice location:
  • Phone: 702-232-3189
  • Fax: 702-233-6713
Mailing address:
  • Phone: 702-636-2843
  • Fax: 702-726-9543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberB598
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberB598
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: