Provider Demographics
NPI:1326583170
Name:PENLEY, JOHN (AT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PENLEY
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1356
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116
Mailing Address - Country:US
Mailing Address - Phone:734-474-0783
Mailing Address - Fax:
Practice Address - Street 1:1630 BOGIE LAKE RD
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48383
Practice Address - Country:US
Practice Address - Phone:734-474-0783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010016452081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine