Provider Demographics
NPI:1801589825
Name:PENROD, HUNTER M (COTA/L)
Entity type:Individual
Prefix:
First Name:HUNTER
Middle Name:M
Last Name:PENROD
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 S CORDOBA AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-3024
Mailing Address - Country:US
Mailing Address - Phone:530-440-5711
Mailing Address - Fax:
Practice Address - Street 1:3410 S CORDOBA AVE
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-3024
Practice Address - Country:US
Practice Address - Phone:530-440-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6452314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility