Healthcare Provider Details

I. General information

NPI: 1982928727
Provider Name (Legal Business Name): LUIS PONCE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 03/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 SPRINGLINE DR
PALMDALE CA
93550-7732
US

IV. Provider business mailing address

1233 SPRINGLINE DR
PALMDALE CA
93550-7732
US

V. Phone/Fax

Practice location:
  • Phone: 661-266-0545
  • Fax:
Mailing address:
  • Phone: 661-266-0545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: