Provider Demographics
NPI:1093986531
Name:PENA, COREY L (CO)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:L
Last Name:PENA
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
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Mailing Address - Street 1:1028 LEE ANN DR NE
Mailing Address - Street 2:SUITE 50
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2903
Mailing Address - Country:US
Mailing Address - Phone:704-654-9279
Mailing Address - Fax:
Practice Address - Street 1:1028 LEE ANN DR NE
Practice Address - Street 2:SUITE 50
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2903
Practice Address - Country:US
Practice Address - Phone:704-654-9279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No174400000XOther Service ProvidersSpecialist