Provider Demographics
NPI:1366950776
Name:DEDICATED PENNSYLVANIA HOLDING, LLC
Entity type:Organization
Organization Name:DEDICATED PENNSYLVANIA HOLDING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-831-4722
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:305-628-6117
Mailing Address - Fax:305-363-5989
Practice Address - Street 1:5675 N. FRONT STRREET
Practice Address - Street 2:SUITE 141
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-1910
Practice Address - Country:US
Practice Address - Phone:305-628-6117
Practice Address - Fax:305-363-5989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-19
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing Site