Provider Demographics
NPI:1083263396
Name:BELLO PONCE, MACKENZIE LUCINDA
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LUCINDA
Last Name:BELLO PONCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6879 GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-1315
Mailing Address - Country:US
Mailing Address - Phone:951-347-2419
Mailing Address - Fax:
Practice Address - Street 1:316 E E ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-3712
Practice Address - Country:US
Practice Address - Phone:909-983-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker