Basic Information
| Provider Information | |||||||||
| NPI: | 1669846747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PONCE | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAC WAIVER | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3601 FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331373795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055766611 | ||||||||
| FaxNumber: | 7864762830 | ||||||||
| Practice Location | |||||||||
| Address1: | 3550 BISCAYNE BLVD | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331373841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055766611 | ||||||||
| FaxNumber: | 7864762830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2015 | ||||||||
| LastUpdateDate: | 11/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | FL | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.