Basic Information
| Provider Information | |||||||||
| NPI: | 1467638700 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PONCE HOME MEDICAL EQUIPMENT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3123 | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320853123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048244990 | ||||||||
| FaxNumber: | 9048242226 | ||||||||
| Practice Location | |||||||||
| Address1: | 665 STATE ROAD 207 | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320845938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048260700 | ||||||||
| FaxNumber: | 9048260800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2008 | ||||||||
| LastUpdateDate: | 02/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | PONCE | ||||||||
| AuthorizedOfficialFirstName: | BETTY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9048260700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | 1313412 | FL | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 032384500 | 05 | FL | MEDICAID | 1313412 | 01 | FL | ACHA LICENSE | OTHER | 1837478 | 01 | FL | AETNA | OTHER | 613159000 | 01 | FL | OWCP - DOL | OTHER | 326649 | 01 | FL | OXYGEN LICENSE | OTHER |