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General NPI Number Information
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NPI Number | 1639622681
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Entity Type | Organization
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Legal Business Name | COSMOLOGICAL LLC
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Dates
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Enumeration Date | 07/26/2016
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Last Update Date | 07/26/2016
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Provider Practice Location Address
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Address Line | 5746 N 19TH ST
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City | PHILADELPHIA
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State | PA
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Zip | 19141-1204
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Country | US
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Telephone | 215-771-1819
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Fax | 215-277-7227
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Provider Business Mailing Address
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Address Line | 5746 N 19TH ST
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City | PHILADELPHIA
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State | PA
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Zip | 19141-1204
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Country | US
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Telephone | 215-771-1819
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Fax | 215-277-7227
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Authorized Official
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Title or Position | OWNER
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Name | MR. CLYDE SANDERS
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Credential |
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Telephone | 215-771-1819
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number |
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License Number State |
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