Healthcare Provider Details

I. General information

NPI: 1790162543
Provider Name (Legal Business Name): LONGEVITY AND ME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15290 WILSHIRE WAY
PEMBROKE PINES FL
33027-2213
US

IV. Provider business mailing address

15290 WILSHIRE WAY
PEMBROKE PINES FL
33027-2213
US

V. Phone/Fax

Practice location:
  • Phone: 305-725-4471
  • Fax:
Mailing address:
  • Phone: 305-725-4471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. ADINE JEAN-GUILLAUME
Title or Position: MGR
Credential: LIC.NURSE/MASSAGE TH
Phone: 305-725-4471