Healthcare Provider Details

I. General information

NPI: 1639043755
Provider Name (Legal Business Name): RADIANT LONGEVITY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E RIDGEWOOD AVE
PARAMUS NJ
07652-3917
US

IV. Provider business mailing address

140 E RIDGEWOOD AVE STE 415
PARAMUS NJ
07652-3915
US

V. Phone/Fax

Practice location:
  • Phone: 201-989-9777
  • Fax: 155-136-1972
Mailing address:
  • Phone: 201-989-9777
  • Fax: 155-136-1972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: RALPHAEL KORBLA KUKUBOR
Title or Position: MANAGER
Credential:
Phone: 201-989-9777