Provider Demographics
NPI:1700357936
Name:GREENE/PENDZICH, CECELIA ROSE (CERTIFIED PERMANENT)
Entity type:Individual
Prefix:MRS
First Name:CECELIA
Middle Name:ROSE
Last Name:GREENE/PENDZICH
Suffix:
Gender:F
Credentials:CERTIFIED PERMANENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7760 FAY AVE, SUITE M.
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-230-2340
Mailing Address - Fax:
Practice Address - Street 1:7760 FAY AVE, SUITE M.
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-230-2340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy FitterGroup - Single Specialty