Healthcare Provider Details

I. General information

NPI: 1053911099
Provider Name (Legal Business Name): ANTWINA BARBER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 RUFFNER ST
PHILADELPHIA PA
19140-2820
US

IV. Provider business mailing address

2240 RUFFNER ST
PHILADELPHIA PA
19140-2820
US

V. Phone/Fax

Practice location:
  • Phone: 267-444-6653
  • Fax:
Mailing address:
  • Phone: 267-444-6653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number27199480
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: