Healthcare Provider Details

I. General information

NPI: 1538586771
Provider Name (Legal Business Name): HEALTHY LIFE AND LONGEVITY MEDICAL OFFICE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

287 NORTHERN BLVD SUIT 106
GREAT NECK NY
11021-4700
US

IV. Provider business mailing address

287 NORTHERN BOULEVARDS SUIT 106
GREAT NECK NY
11021-4347
US

V. Phone/Fax

Practice location:
  • Phone: 917-579-6886
  • Fax:
Mailing address:
  • Phone: 917-579-6886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number233928
License Number StateNY

VIII. Authorized Official

Name: ZHICHENG LU
Title or Position: MEDICAL DIRECTOR
Credential: D.O.
Phone: 917-579-6886