Provider Demographics
NPI:1417437831
Name:PEREZ PONCE, GRACIELA
Entity Type:Individual
Prefix:
First Name:GRACIELA
Middle Name:
Last Name:PEREZ 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 1:1567 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-1350
Mailing Address - Country:US
Mailing Address - Phone:323-836-4566
Mailing Address - Fax:
Practice Address - Street 1:3820 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3625
Practice Address - Country:US
Practice Address - Phone:310-632-0421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist