Provider Demographics
NPI:1306899489
Name:PENNA, ROGER M (DC)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:M
Last Name:PENNA
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 1:2590 NATURE PARK DR STE 135
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-3187
Mailing Address - Country:US
Mailing Address - Phone:702-636-2843
Mailing Address - Fax:702-726-9543
Practice Address - Street 1:2670 CRIMSON CANYON DR STE 150
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0848
Practice Address - Country:US
Practice Address - Phone:702-232-3189
Practice Address - Fax:702-233-6713
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB598111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVU87578Medicare UPIN
NV35542Medicare ID - Type Unspecified