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General NPI Number Information
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NPI Number | 1912509233
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Entity Type | Organization
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Legal Business Name | PENSTAR PROVIDER NETWORK LLC
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Dates
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Enumeration Date | 11/11/2020
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Last Update Date | 11/11/2020
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Provider Practice Location Address
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Address Line | 1931 NW 150TH AVE STE 228
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City | PEMBROKE PINES
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State | FL
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Zip | 33028-2880
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Country | US
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Telephone | 754-226-6456
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Fax |
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Provider Business Mailing Address
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Address Line | 1931 NW 150TH AVE STE 228
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City | PEMBROKE PINES
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State | FL
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Zip | 33028-2880
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Country | US
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Telephone | 754-226-6456
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Fax |
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Authorized Official
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Title or Position | MGR
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Name | ILEANA VILLARREAL
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Credential |
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Telephone | 954-281-5022
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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