Basic Information
| Provider Information | |||||||||
| NPI: | 1477865681 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PONCE PRIMARY CARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PONCE PREVENTIVE CARE LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 402 W PONCE DE LEON AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300302443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045372521 | ||||||||
| FaxNumber: | 4046016727 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 W PONCE DE LEON AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300302443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045372521 | ||||||||
| FaxNumber: | 4046016727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2010 | ||||||||
| LastUpdateDate: | 07/06/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COSTLEY | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | DONALD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4045372521 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 054263 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.