Healthcare Provider Details

I. General information

NPI: 1487252565
Provider Name (Legal Business Name): JUAN ROGELIO PONCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 N ARROWHEAD AVE
SAN BERNARDINO CA
92401-1251
US

IV. Provider business mailing address

175 N INDIAN HILL BLVD STE 205B
CLAREMONT CA
91711-4665
US

V. Phone/Fax

Practice location:
  • Phone: 877-722-2737
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT148187
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: