Provider Demographics
NPI:1225110935
Name:PENCE, DEBRAH BERNICE (RFM)
Entity Type:Individual
Prefix:
First Name:DEBRAH
Middle Name:BERNICE
Last Name:PENCE
Suffix:
Gender:F
Credentials:RFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12402 INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE A-11
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5871
Mailing Address - Country:US
Mailing Address - Phone:760-243-6828
Mailing Address - Fax:760-241-2978
Practice Address - Street 1:12402 INDUSTRIAL BLVD
Practice Address - Street 2:SUITE A-11
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5871
Practice Address - Country:US
Practice Address - Phone:760-243-6828
Practice Address - Fax:760-241-2978
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ52677ZOtherBLUE SHIELD PROVIDER #
CAZZZ52677ZOtherBLUE SHIELD PROVIDER #