Healthcare Provider Details

I. General information

NPI: 1578299558
Provider Name (Legal Business Name): GENESIS INTEGRATIVE MEDICINE LONGEVITY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 11/04/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 MAIN ST
LAKE COMO NJ
07719-3052
US

IV. Provider business mailing address

1716 MAIN ST
LAKE COMO NJ
07719-3052
US

V. Phone/Fax

Practice location:
  • Phone: 732-681-1000
  • Fax: 732-681-1004
Mailing address:
  • Phone: 732-681-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSEPH LOURO
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 732-681-1000