Provider Demographics
NPI:1861907693
Name:GUERRERO PENA, HERSON IVAN (TCM CASE MANAGER FCB)
Entity type:Individual
Prefix:
First Name:HERSON
Middle Name:IVAN
Last Name:GUERRERO PENA
Suffix:
Gender:M
Credentials:TCM CASE MANAGER FCB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4491 ABERDEEN CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6654
Mailing Address - Country:US
Mailing Address - Phone:321-355-0073
Mailing Address - Fax:
Practice Address - Street 1:1071 PORT MALABAR BLVD NE STE 105-106
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5161
Practice Address - Country:US
Practice Address - Phone:321-355-0073
Practice Address - Fax:321-821-6860
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty