Healthcare Provider Details

I. General information

NPI: 1346936564
Provider Name (Legal Business Name): SELINA THAOLY DAO MLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 WOODLAND AVE
PHILADELPHIA PA
19104-4551
US

IV. Provider business mailing address

311 N 41ST ST
PENNSAUKEN NJ
08110-3135
US

V. Phone/Fax

Practice location:
  • Phone: 215-823-5800
  • Fax:
Mailing address:
  • Phone: 215-939-1034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: