Provider Demographics
NPI:1689365637
Name:PENA, VICTORIA (ABOC, NCLEC)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:ABOC, NCLEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 BARLOW RD
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-4363
Mailing Address - Country:US
Mailing Address - Phone:970-542-2291
Mailing Address - Fax:970-542-2294
Practice Address - Street 1:1300 BARLOW RD
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-4363
Practice Address - Country:US
Practice Address - Phone:970-542-2291
Practice Address - Fax:970-542-2294
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
220404156FC0801X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter