Healthcare Provider Details

I. General information

NPI: 1063215796
Provider Name (Legal Business Name): ALEC PUPO
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4170 CITY AVE
PHILADELPHIA PA
19131-1610
US

IV. Provider business mailing address

411 BERRY LN
MEDIA PA
19063-1160
US

V. Phone/Fax

Practice location:
  • Phone: 215-871-6100
  • Fax:
Mailing address:
  • Phone: 610-585-9179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: