Provider Demographics
NPI:1447947445
Name:PENCHALA, ASHWIN
Entity type:Individual
Prefix:
First Name:ASHWIN
Middle Name:
Last Name:PENCHALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19832 MARIPOSA PINES WAY
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-4138
Mailing Address - Country:US
Mailing Address - Phone:224-704-3653
Mailing Address - Fax:
Practice Address - Street 1:1117 E DEVONSHIRE AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-3083
Practice Address - Country:US
Practice Address - Phone:224-704-3653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty