Basic Information
| Provider Information | |||||||||
| NPI: | 1750536751 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENNY LANE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 SIERRA CT | ||||||||
| Address2: | |||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935507607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612744883 | ||||||||
| FaxNumber: | 6612721005 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 SIERRA CT | ||||||||
| Address2: | |||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935507607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612744883 | ||||||||
| FaxNumber: | 6612721005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2008 | ||||||||
| LastUpdateDate: | 11/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | LESTER | ||||||||
| AuthorizedOfficialTitleorPosition: | CHILD AND FAMILY SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6612744883 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.