Provider Demographics
NPI:1447416250
Name:LYCEUM CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:LYCEUM CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEZZELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-508-5555
Mailing Address - Street 1:445 LYCEUM AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3420
Mailing Address - Country:US
Mailing Address - Phone:215-508-5555
Mailing Address - Fax:
Practice Address - Street 1:445 LYCEUM AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-3420
Practice Address - Country:US
Practice Address - Phone:215-508-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA008325111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAX6V741Medicare PIN