Healthcare Provider Details

I. General information

NPI: 1568632396
Provider Name (Legal Business Name): LIVE LONGER PHYSICIANS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 N ROBERTS AVE
ARCADIA FL
34266-8957
US

IV. Provider business mailing address

833 N ROBERTS AVE
ARCADIA FL
34266-8957
US

V. Phone/Fax

Practice location:
  • Phone: 863-993-1999
  • Fax: 863-993-0924
Mailing address:
  • Phone: 863-993-1999
  • Fax: 863-993-0924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME19425
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME19425
License Number StateFL

VIII. Authorized Official

Name: DON E STEWART
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 863-244-9585