Healthcare Provider Details

I. General information

NPI: 1730924366
Provider Name (Legal Business Name): FA5 ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CRESCENT DR STE 300
PHILADELPHIA PA
19112-1015
US

IV. Provider business mailing address

9 HERALD PL
ASTON PA
19014-2103
US

V. Phone/Fax

Practice location:
  • Phone: 215-389-3161
  • Fax: 215-389-1036
Mailing address:
  • Phone: 610-803-3745
  • Fax: 215-389-1036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: JOYCE LYNN RICKS
Title or Position: CREDENTIALING
Credential:
Phone: 610-803-3745