Healthcare Provider Details

I. General information

NPI: 1720796196
Provider Name (Legal Business Name): LONGEVITY LONG TERM MEDICAL CARE OF PENNSYLVANIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2595 INTERSTATE DR STE 103
HARRISBURG PA
17110-9378
US

IV. Provider business mailing address

11770 US HIGHWAY 1 STE N107
PALM BEACH GARDENS FL
33408-3027
US

V. Phone/Fax

Practice location:
  • Phone: 561-815-2427
  • Fax:
Mailing address:
  • Phone: 561-815-2427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANE VINCUR
Title or Position: PRACTICE MANAGER
Credential:
Phone: 561-815-2427