MEDICARE: LVC C-CLASS REALTY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	163WA2000X	Administrator Registered Nurse
2	163WC0200X	Critical Care Medicine Registered Nurse
3	163WG0000X	General Practice Registered Nurse
4	163W00000X	Registered Nurse

General Provider Information

NPI Number	:	1750186847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LVC C-CLASS REALTY, LLC

Provider Business Mailing Address
First Line	:	2640 N MYRTLEWOOD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-3041
Country	:	US
Telephone Number	:	267-981-7999
Fax Number	:

Provider Business Practice Location Address
First Line	:	2539 N MYRTLEWOOD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-3026
Country	:	US
Telephone Number	:	267-225-4360
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	REGINALD CUMMINGS
Credential	:	R.PH., MBA
Telephone Number	:	267-225-4360

Provider Enumeration Date	:	02/13/2025
Last Update Date	:	02/13/2025

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