Basic Information
| Provider Information | |||||||||
| NPI: | 1952748501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DE LA PENA EYE CLINIC, A MEDICAL GROUP, INC | ||||||||
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| OtherOrganizationName: | DE LA PENA EYE CLINIC, AMG, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 COMMERCE ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372192518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153456900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7100 VAN NUYS BLVD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914053063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189881111 | ||||||||
| FaxNumber: | 8189881261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2013 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER, BOARD OF MANAGERS | ||||||||
| AuthorizedOfficialTelephone: | 6153456900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.