Provider Demographics
NPI:1760199491
Name:PONCE, MARIO C JR (PT)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:C
Last Name:PONCE
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 ROCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975
Mailing Address - Country:US
Mailing Address - Phone:574-201-9975
Mailing Address - Fax:
Practice Address - Street 1:1729 WABASH AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46975-2455
Practice Address - Country:US
Practice Address - Phone:574-475-8518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004455A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist