Healthcare Provider Details

I. General information

NPI: 1104642941
Provider Name (Legal Business Name): LONGLIFE HEALTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N. MAIN ST. EXT. BLDG 2, STE 3C
WALLINGFORD CT
06492-2400
US

IV. Provider business mailing address

850 N. MAIN ST. EXT. BLDG 2, STE 3C
WALLINGFORD CT
06492-2400
US

V. Phone/Fax

Practice location:
  • Phone: 203-284-8661
  • Fax: 203-284-1050
Mailing address:
  • Phone: 203-284-8661
  • Fax: 203-284-1050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA BUCKLEY
Title or Position: MEMBER
Credential: L.AC.
Phone: 203-284-8661