Basic Information
| Provider Information | |||||||||
| NPI: | 1790351377 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIAN DENA DO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 872 | ||||||||
| Address2: | |||||||||
| City: | AGOURA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913760872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185187226 | ||||||||
| FaxNumber: | 8186712225 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 MEDICAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238059280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108456576 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2021 | ||||||||
| LastUpdateDate: | 07/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | DENA | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8045853147 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 07/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0102205373 | 01 | VA | MEDICAL LICENSE | OTHER |