Provider Demographics
NPI:1164627436
Name:BADO, AUDRA PONCI (MPT)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:PONCI
Last Name:BADO
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12099 W. WASHINGTON BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:CULVER CITE
Mailing Address - State:CA
Mailing Address - Zip Code:90066
Mailing Address - Country:US
Mailing Address - Phone:213-935-8566
Mailing Address - Fax:310-535-0009
Practice Address - Street 1:12099 W WASHINGTON BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-2621
Practice Address - Country:US
Practice Address - Phone:213-935-8566
Practice Address - Fax:310-535-0009
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26768225100000X, 2251H1200X
2251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist