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General NPI Number Information
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NPI Number | 1588107668
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Entity Type | Organization
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Legal Business Name | BUSTLETON HEALTHCARE
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Dates
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Enumeration Date | 11/22/2016
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Last Update Date | 11/22/2016
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Provider Practice Location Address
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Address Line | 9867 BUSTLETON AVE SUITE B
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City | PHILADELPHIA
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State | PA
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Zip | 19115-2611
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Country | US
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Telephone | 215-698-9295
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Fax |
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Provider Business Mailing Address
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Address Line | 9867 BUSTLETON AVE SUITE B
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City | PHILADELPHIA
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State | PA
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Zip | 19115-2611
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | IRINA JOUKOVA
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Credential |
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Telephone | 267-307-9236
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | MD 435017
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | MD 435017
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License Number State | PA
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