Provider Demographics
NPI:1477865681
Name:PONCE PRIMARY CARE LLC
Entity Type:Organization
Organization Name:PONCE PRIMARY CARE LLC
Other - Org Name:PONCE PREVENTIVE CARE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-537-2521
Mailing Address - Street 1:315 W PONCE DE LEON AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2441
Mailing Address - Country:US
Mailing Address - Phone:404-537-2521
Mailing Address - Fax:844-246-7292
Practice Address - Street 1:315 W PONCE DE LEON AVE STE 110
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2441
Practice Address - Country:US
Practice Address - Phone:404-537-2521
Practice Address - Fax:844-246-7292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
GA054263261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty