Provider Demographics
NPI:1790924017
Name:BLACKWOOD PONCE, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BLACKWOOD 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 1:447 N EL MOLINO AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1403
Mailing Address - Country:US
Mailing Address - Phone:626-577-8480
Mailing Address - Fax:626-577-8978
Practice Address - Street 1:43807 10TH ST W STE D
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4805
Practice Address - Country:US
Practice Address - Phone:661-575-9365
Practice Address - Fax:661-575-9502
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator