Organization
PENNY R. VANDESTREEK DO, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PENNY R VANDESTREEK DO (PRESIDENT)
(916) 781-1292
Entity
Organization
Contact information
Practice address
1 MEDICAL PLAZA DR, ATT NUCLEAR MEDICINE, ROSEVILLE, CA 95661-3037
(916) 781-1292
(916) 663-9912
Mailing address
PO BOX 1328, ROCKLIN, CA 95677-7328
(916) 781-1292
(916) 663-9912
Taxonomy
Speciality
Code
Description
License number
State
207UN0902X
Nuclear Imaging & Therapy Physician
Primary
20A6232
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00AX62320
—
CA
01
—
P00017739
RAILROAD MEDICARE
—
Enumeration date
10/26/2007
Last updated
06/30/2008
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