Provider Demographics
NPI:1578668869
Name:PONCE PLAZA INC
Entity Type:Organization
Organization Name:PONCE PLAZA INC
Other - Org Name:PONCE PLAZA NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEBASTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:305-545-6695
Mailing Address - Street 1:335 SW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-2011
Mailing Address - Country:US
Mailing Address - Phone:305-545-6695
Mailing Address - Fax:305-545-0398
Practice Address - Street 1:335 SW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-2011
Practice Address - Country:US
Practice Address - Phone:305-545-6695
Practice Address - Fax:305-545-0398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11400961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106021Medicare Oscar/Certification