MEDICARE: CHARLES PENICK

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	207Q00000X	Family Medicine Physician	M-15738	ID

General Provider Information

NPI Number	:	1871970806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES PENICK

Provider Business Mailing Address
First Line	:	5655 N GLENWOOD ST STE 105
Second Line	:
City	:	GARDEN CITY
State	:	ID
Zip	:	83714-1831
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	27335 TOURNEY RD STE 100
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91355-2200
Country	:	US
Telephone Number	:	661-338-5983
Fax Number	:

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

Provider Enumeration Date	:	04/28/2015
Last Update Date	:	12/05/2024

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Directions to “ CHARLES PENICK ” Practice Location

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