Healthcare Provider Details

I. General information

NPI: 1396999280
Provider Name (Legal Business Name): TUSTIN LONGEVITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 11/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13422 NEWPORT AVE SUITE L
TUSTIN CA
92780-3746
US

IV. Provider business mailing address

13422 NEWPORT AVE SUITE L
TUSTIN CA
92780-3746
US

V. Phone/Fax

Practice location:
  • Phone: 714-544-1521
  • Fax: 714-544-1904
Mailing address:
  • Phone: 714-544-1521
  • Fax: 714-544-1904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ELAINE DALY
Title or Position: OFFICE MANAGER
Credential:
Phone: 714-544-1521