Provider Demographics
NPI:1831666585
Name:LYCEUM LONGEVITY CENTER PLLC
Entity Type:Organization
Organization Name:LYCEUM LONGEVITY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEZZELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-508-5555
Mailing Address - Street 1:6062 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1647
Mailing Address - Country:US
Mailing Address - Phone:215-508-5555
Mailing Address - Fax:215-508-5555
Practice Address - Street 1:6062 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1647
Practice Address - Country:US
Practice Address - Phone:215-508-5555
Practice Address - Fax:215-508-5555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-31
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty