Provider Demographics
NPI:1306019856
Name:LANNY C. PELLICCIA DPM
Entity Type:Organization
Organization Name:LANNY C. PELLICCIA DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LANNY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PELLICCIA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:570-283-3668
Mailing Address - Street 1:270 PIERCE ST
Mailing Address - Street 2:STE 301
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5141
Mailing Address - Country:US
Mailing Address - Phone:570-283-3668
Mailing Address - Fax:570-283-0309
Practice Address - Street 1:270 PIERCE ST
Practice Address - Street 2:STE 301
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5141
Practice Address - Country:US
Practice Address - Phone:570-283-3668
Practice Address - Fax:570-283-0309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-003688-L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0756710001Medicare NSC