# PONCE MEDICLUB LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1902468523
- **Authorized official:** MARIA LOPEZ (DIRECTOR OF OPERATIONS MED CTR)
- **Authorized official phone:** (305) 992-4521

## Contact information

- **Practice address:** 9950 SW 107TH AVE STE 203, MIAMI, FL 33176-2767
- **Practice address phone:** (305) 908-3144
- **Practice address fax:** (407) 605-5129
- **Mailing address:** 11455 SW 40TH ST \# 146, MIAMI, FL 33165-3311
- **Mailing address phone:** (305) 908-3144
- **Mailing address fax:** (407) 605-5129

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | — | — | Yes |

## Other

- **Enumeration date:** 07/03/2019
- **Last updated:** 05/12/2022