Provider Demographics
NPI:1144723545
Name:PENA, CARLOS ANTONIO (DC)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:ANTONIO
Last Name:PENA
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 1:1020 CHEROKEE TRL
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-3606
Mailing Address - Country:US
Mailing Address - Phone:404-984-8465
Mailing Address - Fax:
Practice Address - Street 1:19273 NW 27TH AVE APT 3412
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-2577
Practice Address - Country:US
Practice Address - Phone:404-984-8465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010025111N00000X
FLCH13049111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor