Healthcare Provider Details

I. General information

NPI: 1477146058
Provider Name (Legal Business Name): LONGEVITY WELLNESS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2021
Last Update Date: 02/16/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 ROCHELLE AVE
ROCHELLE PARK NJ
07662-3914
US

IV. Provider business mailing address

201 W PASSAIC ST STE 301
ROCHELLE PARK NJ
07662-3126
US

V. Phone/Fax

Practice location:
  • Phone: 201-291-1616
  • Fax: 201-291-1619
Mailing address:
  • Phone: 201-291-1616
  • Fax: 201-291-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHEN J CONTE
Title or Position: PRESIDENT
Credential: DO
Phone: 201-291-1616