MEDICARE: MRS. AVITAL PENINA EIS M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1184900953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AVITAL PENINA EIS M.S.

Provider Business Mailing Address
First Line	:	2420 OCEAN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-3509
Country	:	US
Telephone Number	:	516-776-8072
Fax Number	:

Provider Business Practice Location Address
First Line	:	2420 OCEAN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-3509
Country	:	US
Telephone Number	:	516-776-8072
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2011
Last Update Date	:	10/25/2011

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