Healthcare Provider Details

I. General information

NPI: 1831797679
Provider Name (Legal Business Name): ETHEL LEE ZACHARY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 LANSDOWNE AVE APT G2
PHILADELPHIA PA
19131-3916
US

IV. Provider business mailing address

5400 LANSDOWNE AVE APT G2
PHILADELPHIA PA
19131-3916
US

V. Phone/Fax

Practice location:
  • Phone: 267-386-6361
  • Fax:
Mailing address:
  • Phone: 267-386-6361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. AMANHOTEP J PARKER VI
Title or Position: CEO
Credential:
Phone: 267-386-6361