Provider Demographics
NPI:1295092880
Name:PENG, YEN WEN (DC)
Entity type:Individual
Prefix:
First Name:YEN WEN
Middle Name:
Last Name:PENG
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 1:1569 FAIRWAY DR
Mailing Address - Street 2:#238
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-3418
Mailing Address - Country:US
Mailing Address - Phone:909-468-5099
Mailing Address - Fax:909-468-1599
Practice Address - Street 1:1569 FAIRWAY DR
Practice Address - Street 2:#238
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-3418
Practice Address - Country:US
Practice Address - Phone:909-468-5099
Practice Address - Fax:909-468-1599
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28524111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94721Medicare UPIN