Healthcare Provider Details

I. General information

NPI: 1831575315
Provider Name (Legal Business Name): EVARISTUS PENDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 SW 30TH CT
MOORE OK
73160-2887
US

IV. Provider business mailing address

9500 SW 33RD ST
OKLAHOMA CITY OK
73179-1212
US

V. Phone/Fax

Practice location:
  • Phone: 405-676-5114
  • Fax:
Mailing address:
  • Phone: 405-408-4073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10061
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: