Healthcare Provider Details

I. General information

NPI: 1477865681
Provider Name (Legal Business Name): PONCE PREVENTIVE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W PONCE DE LEON AVE STE 110
DECATUR GA
30030-2441
US

IV. Provider business mailing address

315 W PONCE DE LEON AVE STE 110
DECATUR GA
30030-2441
US

V. Phone/Fax

Practice location:
  • Phone: 404-537-2521
  • Fax: 844-246-7292
Mailing address:
  • Phone: 404-537-2521
  • Fax: 844-246-7292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number054263
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROSA FIGUEROA
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 404-537-2521