Provider Demographics
NPI:1144798448
Name:PENN, RONALD JR
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:
Last Name:PENN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4751 HARVEST PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-4776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4751 HARVEST PARK DR.
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125
Practice Address - Country:US
Practice Address - Phone:323-558-2902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services