Healthcare Provider Details

I. General information

NPI: 1548514474
Provider Name (Legal Business Name): DR MELISSA PONCE- FUNCTIONAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 N EL CAMINO REAL STE. 101
SAN MATEO CA
94401-3713
US

IV. Provider business mailing address

654 N EL CAMINO REAL STE. 101
SAN MATEO CA
94401-3713
US

V. Phone/Fax

Practice location:
  • Phone: 650-242-9202
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberDC31510
License Number StateCA

VIII. Authorized Official

Name: MELISSA PONCE
Title or Position: OWNER
Credential: DC
Phone: 909-260-2181