Healthcare Provider Details

I. General information

NPI: 1790931871
Provider Name (Legal Business Name): PONCE HOME MEDICAL EQUIPMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 PLANTATION ISLAND DR S SUITE 140
ST AUGUSTINE FL
32080-6188
US

IV. Provider business mailing address

PO BOX 3123
ST AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 904-461-9050
  • Fax: 904-461-9060
Mailing address:
  • Phone: 904-824-4990
  • Fax: 904-824-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1313412
License Number StateFL

VIII. Authorized Official

Name: BETTY CARVAJAL-PANTALEON
Title or Position: OWNER
Credential: M.S.
Phone: 904-461-9050