Provider Demographics
NPI:1487300562
Name:PENDER ATHLETIC BRANDS, INC.
Entity type:Organization
Organization Name:PENDER ATHLETIC BRANDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-896-3234
Mailing Address - Street 1:1822 N HABITAT DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-1366
Mailing Address - Country:US
Mailing Address - Phone:931-896-3234
Mailing Address - Fax:
Practice Address - Street 1:250 RED CLIFFS DR STE 36
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-8129
Practice Address - Country:US
Practice Address - Phone:540-300-2626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-26
Last Update Date:2022-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12704436-4701OtherMASSAGE THERAPY LICENSE