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NPI Code Detail

MEDICARE: LONGEVITY CENTER LLC

MEDICARE: LONGEVITY CENTER LLC
Medicare Provider Information

Scope of Practice

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

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician5101007920MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1144499195
Entity Type Code : Organization
Provider Name (Legal Business Name) : LONGEVITY CENTER LLC
Provider Business Mailing Address
First Line : 2251 E PARIS AVE SE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49546-2431
Country : US
Telephone Number : 616-956-6090
Fax Number : 616-956-6099
Provider Business Practice Location Address
First Line : 2251 E PARIS AVE SE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49546-2431
Country : US
Telephone Number : 616-956-6090
Fax Number : 616-956-6099
Authorized Official
Title or Position : BILLING MANAGER
Name : MRS. CHERYL LYNN ALLEN
Credential :
Telephone Number : 616-897-2142
Provider Enumeration Date : 02/25/2008
Last Update Date : 05/14/2009

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Directions to “LONGEVITY CENTER LLC ” Practice Location

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