Provider Demographics
NPI:1093100133
Name:PENA, GILBERTO JR (LMT)
Entity Type:Individual
Prefix:
First Name:GILBERTO
Middle Name:
Last Name:PENA
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4994 WILLOW CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4375
Mailing Address - Country:US
Mailing Address - Phone:678-848-5020
Mailing Address - Fax:
Practice Address - Street 1:4994 WILLOW CREEK DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4375
Practice Address - Country:US
Practice Address - Phone:678-848-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009410225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist