Provider Demographics
NPI:1164131017
Name:PONCE, KEITH (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:PONCE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 S SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3940
Mailing Address - Country:US
Mailing Address - Phone:858-308-1413
Mailing Address - Fax:
Practice Address - Street 1:1115 S SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3940
Practice Address - Country:US
Practice Address - Phone:626-962-4011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist