Organization
LYCEUM LONGEVITY CENTER PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WILLIAM J PEZZELLO (CO-FOUNDER)
(215) 508-5555
Entity
Organization
Contact information
Practice address
6062 RIDGE AVE, PHILADELPHIA, PA 19128-1647
(215) 508-5555
(215) 508-5555
Mailing address
6062 RIDGE AVE, PHILADELPHIA, PA 19128-1647
(215) 508-5555
(215) 508-5555
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
—
—
174400000X
Specialist
Primary
—
—
2085R0202X
Diagnostic Radiology Physician
—
—
Other
Enumeration date
10/31/2018
Last updated
10/04/2019
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