Healthcare Provider Details

I. General information

NPI: 1326878299
Provider Name (Legal Business Name): LONGEVITY CLINICAL LTC ASSOCIATES OF TENNESSEE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 MAIN ST
RED BOILING SPRINGS TN
37150-2149
US

IV. Provider business mailing address

11780 US HIGHWAY 1 STE N107
NORTH PALM BEACH FL
33408-3007
US

V. Phone/Fax

Practice location:
  • Phone: 615-699-2238
  • 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 TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
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: PRACTICE MANAGER
Phone: 561-815-2427