Healthcare Provider Details

I. General information

NPI: 1174442008
Provider Name (Legal Business Name): LONGEVITY AND PERFORMANCE CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 HILLCREST CENTER CIR
WINSTON SALEM NC
27103-3048
US

IV. Provider business mailing address

64 ABBOTTSFORD DR
PINEHURST NC
28374-9756
US

V. Phone/Fax

Practice location:
  • Phone: 336-754-3500
  • Fax:
Mailing address:
  • Phone: 336-442-9005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: TODD MICHAEL REITER
Title or Position: OWNER
Credential:
Phone: 336-442-9005