Provider Demographics
NPI:1437315934
Name:PENKA, RACHELLE (OD)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:PENKA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 N DEAN ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-1503
Mailing Address - Country:US
Mailing Address - Phone:864-583-3125
Mailing Address - Fax:864-542-1367
Practice Address - Street 1:180 N DEAN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1503
Practice Address - Country:US
Practice Address - Phone:864-583-3125
Practice Address - Fax:864-542-1367
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1532OtherSTATE LICENSE NUMBER