=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114322070
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICTOR PENAGOS HSE 11988
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2014
-----------------------------------------------------
Last Update Date | 11/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22198 BELLA LAGO DR APT 1118
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433-4839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-777-9952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22198 BELLA LAGO DR APT 1118
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433-4839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-419-7295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | HSE 11988
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------