MEDICARE: RANDALL PENA

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1982080594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL PENA

Provider Business Mailing Address
First Line	:	411 RAILROAD AVE APT 1
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-3934
Country	:	US
Telephone Number	:	505-454-5128
Fax Number	:	505-454-0397

Provider Business Practice Location Address
First Line	:	411 RAILROAD AVE APT 1
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-3934
Country	:	US
Telephone Number	:	505-454-5128
Fax Number	:	505-454-0397

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

Provider Enumeration Date	:	08/05/2015
Last Update Date	:	08/05/2015

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Directions to “ RANDALL PENA ” Practice Location

Language	Start Address	Practice Location

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