Healthcare Provider Details

I. General information

NPI: 1497474035
Provider Name (Legal Business Name): SOUL FOOD NEAR ME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4583 TACONY ST FL 1
PHILA PA
19124-4135
US

IV. Provider business mailing address

4583 TACONY ST FL 1
PHILA PA
19124-4135
US

V. Phone/Fax

Practice location:
  • Phone: 484-716-5426
  • Fax:
Mailing address:
  • Phone: 484-716-5426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State

VIII. Authorized Official

Name: DOMINIQUE MOSLEY
Title or Position: MANAGER
Credential:
Phone: 484-716-5426