Provider Demographics
NPI:1790077543
Name:PONCIANO WELLNESS, LLC
Entity Type:Organization
Organization Name:PONCIANO WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING MANAGER/ PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROXANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMBDIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:888-568-5640
Mailing Address - Street 1:5212 KATELLA AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2828
Mailing Address - Country:US
Mailing Address - Phone:888-568-5640
Mailing Address - Fax:562-493-0922
Practice Address - Street 1:5212 KATELLA AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2828
Practice Address - Country:US
Practice Address - Phone:888-568-5640
Practice Address - Fax:562-493-0922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15130103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1326094442OtherNPPES