Provider Demographics
NPI:1407979610
Name:PENA, GONZALO J (DC)
Entity Type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:J
Last Name:PENA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3465 PARSONS RUN
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1093
Mailing Address - Country:US
Mailing Address - Phone:678-770-5433
Mailing Address - Fax:770-887-8724
Practice Address - Street 1:3465 PARSONS RUN
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1093
Practice Address - Country:US
Practice Address - Phone:678-770-5433
Practice Address - Fax:770-887-8724
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1459111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor