Basic Information
| Provider Information | |||||||||
| NPI: | 1376972646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PONTIS | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | PONTIS | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | J | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 201 S MILLER ST | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934545233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059259811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 201 S MILLER ST | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934545233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059259811 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2013 | ||||||||
| LastUpdateDate: | 11/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.