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General NPI Number Information
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NPI Number | 1518137579
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Entity Type | Organization
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Legal Business Name | LU PONCE MD PC
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Dates
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Enumeration Date | 03/06/2008
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Last Update Date | 03/06/2008
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Provider Practice Location Address
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Address Line | 102 W KNIGHT ST
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City | PORTLAND
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State | TN
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Zip | 37148-1415
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Country | US
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Telephone | 615-325-2821
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Fax | 615-325-9742
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Provider Business Mailing Address
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Address Line | 102 W KNIGHT ST
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City | PORTLAND
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State | TN
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Zip | 37148-1415
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Country | US
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Telephone | 615-325-2821
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Fax | 615-325-9742
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Authorized Official
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Title or Position | OWNER
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Name | DR. LU PONCE
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Credential | MD
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Telephone | 615-325-2821
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 7332
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License Number State | TN
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