Healthcare Provider Details

I. General information

NPI: 1154907855
Provider Name (Legal Business Name): LONGEVITY CLINICAL LTC ASSOCIATES OF NORTH CAROLINA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 STATESVILLE BLVD
SALISBURY NC
28144-2201
US

IV. Provider business mailing address

11770 US 1 STE 101
PALM BEACH GARDENS FL
33408-3000
US

V. Phone/Fax

Practice location:
  • Phone: 704-633-7390
  • Fax:
Mailing address:
  • Phone: 561-444-0710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DAVID C WHYBREW
Title or Position: MARKET PRESIDENT, LHP OKLAHOMA
Credential:
Phone: 918-859-5334