Provider Demographics
NPI:1356589741
Name:ANNA M PENNINO OD OPTOMETRIC CORP
Entity type:Organization
Organization Name:ANNA M PENNINO OD OPTOMETRIC CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PENNINO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-577-6401
Mailing Address - Street 1:8511 PERSHING DR
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-8101
Mailing Address - Country:US
Mailing Address - Phone:310-577-6401
Mailing Address - Fax:310-577-6403
Practice Address - Street 1:8511 PERSHING DR
Practice Address - Street 2:
Practice Address - City:PLAYA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90293-8101
Practice Address - Country:US
Practice Address - Phone:310-577-6401
Practice Address - Fax:310-577-6403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9996T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABG587AMedicare PIN