Individual
EKA MAISURADZE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
8336 BUSTLETON AVE, PHILADELPHIA, PA 19152-1909
(215) 742-9811
Mailing address
8336 BUSTLETON AVE, PHILADELPHIA, PA 19152-1909
(215) 742-9811
Taxonomy
Speciality
Code
Description
License number
State
174200000X
Meals Provider
Primary
—
—
Other
Enumeration date
05/05/2020
Last updated
05/05/2020
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