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General NPI Number Information
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NPI Number | 1558540526
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Entity Type | Organization
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Legal Business Name | PENNY R. VANDESTREEK DO, INC.
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Dates
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Enumeration Date | 10/26/2007
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Last Update Date | 06/30/2008
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Provider Practice Location Address
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Address Line | 1 MEDICAL PLAZA DR ATT NUCLEAR MEDICINE
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City | ROSEVILLE
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State | CA
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Zip | 95661-3037
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Country | US
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Telephone | 916-781-1292
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Fax | 916-663-9912
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Provider Business Mailing Address
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Address Line | PO BOX 1328
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City | ROCKLIN
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State | CA
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Zip | 95677-7328
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Country | US
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Telephone | 916-781-1292
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Fax | 916-663-9912
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Authorized Official
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Title or Position | PRESIDENT
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Name | PENNY R VANDESTREEK
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Credential | DO
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Telephone | 916-781-1292
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207UN0902X
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Taxonomy Name | Nuclear Imaging & Therapy Physician
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License Number | 20A6232
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License Number State | CA
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