Individual
MR. EDWARD LEE PONCE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
1111 TRINITY LN STE 111, BLOOMINGTON, IL 61704-8112
(309) 663-6461
(309) 663-5711
Mailing address
1111 TRINITY LN STE 111, BLOOMINGTON, IL 61704-8112
(309) 663-6461
(309) 663-5711
Taxonomy
Speciality
Code
Description
License number
State
208100000X
Physical Medicine & Rehabilitation Physician
Primary
070-010014
IL
2251X0800X
Orthopedic Physical Therapist
070010014
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
619710010
MEDICARE PTAN
IL
Enumeration date
08/25/2006
Last updated
01/04/2018
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