Provider Demographics
NPI:1790931871
Name:PONCE HOME MEDICAL EQUIPMENT, INC.
Entity Type:Organization
Organization Name:PONCE HOME MEDICAL EQUIPMENT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARVAJAL-PANTALEON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:904-461-9050
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-824-4990
Mailing Address - Fax:904-824-2226
Practice Address - Street 1:1100 PLANTATION ISLAND DR S
Practice Address - Street 2:SUITE 140
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-6188
Practice Address - Country:US
Practice Address - Phone:904-461-9050
Practice Address - Fax:904-461-9060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1313412332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000535300Medicaid
FL613159001OtherDOL
FL000535300Medicaid
FL6096210002Medicare NSC
FL613159001OtherDOL