Healthcare Provider Details

I. General information

NPI: 1154992196
Provider Name (Legal Business Name): LONGEVITY CLINICAL LTC ASSOCIATES OF MICHIGAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26505 POWERS AVE
DEARBORN HEIGHTS MI
48125-1327
US

IV. Provider business mailing address

11770 US HIGHWAY 1 STE 102E
PALM BEACH GARDENS FL
33408-3052
US

V. Phone/Fax

Practice location:
  • Phone: 313-291-6200
  • Fax:
Mailing address:
  • Phone: 561-815-2427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANE VINCUR
Title or Position: CLINICAL SUPPORT TALENT SPECIALIST
Credential:
Phone: 561-815-2427