Provider Demographics
NPI:1306850250
Name:DE LA PENA EYE CLINIC, A MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:DE LA PENA EYE CLINIC, A MEDICAL GROUP, INC
Other - Org Name:DE LA PENA EYE CLINIC, AMG, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER, BOARD OF MANAGERS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-345-6900
Mailing Address - Street 1:401 COMMERCE ST STE 600
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-2518
Mailing Address - Country:US
Mailing Address - Phone:615-345-6900
Mailing Address - Fax:
Practice Address - Street 1:139 S ALVARADO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057
Practice Address - Country:US
Practice Address - Phone:213-484-0170
Practice Address - Fax:213-484-0246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW8760AMedicare ID - Type Unspecified