Healthcare Provider Details

I. General information

NPI: 1902718661
Provider Name (Legal Business Name): THE LONGEVITY SOCIETY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 NW 70TH AVE STE 7
PLANTATION FL
33317-2911
US

IV. Provider business mailing address

2633 OAK PARK CIR
DAVIE FL
33328-6724
US

V. Phone/Fax

Practice location:
  • Phone: 954-494-8799
  • Fax:
Mailing address:
  • Phone: 786-443-2629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NANCY N FONG-EDWARDS
Title or Position: CEO
Credential: APRN
Phone: 786-443-2629