1790931871 NPI number — PONCE HOME MEDICAL EQUIPMENT, INC.

Table of content: (NPI 1790931871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790931871 NPI number — PONCE HOME MEDICAL EQUIPMENT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PONCE HOME MEDICAL EQUIPMENT, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790931871
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3123
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32085-3123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-824-4990
Provider Business Mailing Address Fax Number:
904-824-2226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 PLANTATION ISLAND DR S
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32080-6188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-461-9050
Provider Business Practice Location Address Fax Number:
904-461-9060
Provider Enumeration Date:
08/08/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CARVAJAL-PANTALEON
Authorized Official First Name:
BETTY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
904-461-9050

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1313412 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000535300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 613159001 . This is a "DOL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".