Provider Demographics
NPI:1669740460
Name:AMANDO PENA JR
Entity type:Organization
Organization Name:AMANDO PENA JR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:PENA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:956-488-8048
Mailing Address - Street 1:7251 E HWY 83
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78582-6347
Mailing Address - Country:US
Mailing Address - Phone:956-488-8048
Mailing Address - Fax:956-488-0476
Practice Address - Street 1:7251 E HWY 83
Practice Address - Street 2:
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582-6347
Practice Address - Country:US
Practice Address - Phone:956-488-8048
Practice Address - Fax:956-488-0476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000795332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies