Provider Demographics
NPI:1073952891
Name:PONCHER, KATHLEEN E (LAC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:PONCHER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90402-2117
Mailing Address - Country:US
Mailing Address - Phone:310-433-8500
Mailing Address - Fax:
Practice Address - Street 1:2901 WILSHIRE BLVD
Practice Address - Street 2:SUITE 233
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4901
Practice Address - Country:US
Practice Address - Phone:310-433-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15394171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist