Provider Demographics
NPI:1255969788
Name:PONCIANO, JOSE REAL CATAYOC (LVN)
Entity type:Individual
Prefix:
First Name:JOSE REAL
Middle Name:CATAYOC
Last Name:PONCIANO
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9274 JUNEBERRY LN
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-7821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3580 WILSHIRE BLVD STE 1000
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2544
Practice Address - Country:US
Practice Address - Phone:213-296-3783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA239121164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse