MEDICARE: LYCEUM LONGEVITY CENTER PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	111N00000X	Chiropractor
2	2085R0202X	Diagnostic Radiology Physician
3	174400000X	Specialist

General Provider Information

NPI Number	:	1831666585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYCEUM LONGEVITY CENTER PLLC

Provider Business Mailing Address
First Line	:	6062 RIDGE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19128-1647
Country	:	US
Telephone Number	:	215-508-5555
Fax Number	:	215-508-5555

Provider Business Practice Location Address
First Line	:	6062 RIDGE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19128-1647
Country	:	US
Telephone Number	:	215-508-5555
Fax Number	:	215-508-5555

Authorized Official
Title or Position	:	CO-FOUNDER
Name	:	WILLIAM J PEZZELLO
Credential	:
Telephone Number	:	215-508-5555

Provider Enumeration Date	:	10/31/2018
Last Update Date	:	10/04/2019

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