Basic Information
| Provider Information | |||||||||
| NPI: | 1366950776 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEDICATED PENNSYLVANIA HOLDING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056286117 | ||||||||
| FaxNumber: | 3053635989 | ||||||||
| Practice Location | |||||||||
| Address1: | 5675 N. FRONT STRREET | ||||||||
| Address2: | SUITE 141 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191201910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056286117 | ||||||||
| FaxNumber: | 3053635989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2018 | ||||||||
| LastUpdateDate: | 03/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | JIMENEZ | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 1786870403 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 174400000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.