Provider Demographics
NPI:1699906198
Name:PENNY LANE
Entity type:Organization
Organization Name:PENNY LANE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFS
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:MARQUIS
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-272-4883
Mailing Address - Street 1:190 SIERRA CT
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-7607
Mailing Address - Country:US
Mailing Address - Phone:661-272-4883
Mailing Address - Fax:661-272-1005
Practice Address - Street 1:190 SIERRA CT
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7607
Practice Address - Country:US
Practice Address - Phone:661-272-4883
Practice Address - Fax:661-272-1005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health