Healthcare Provider Details

I. General information

NPI: 1831015577
Provider Name (Legal Business Name): REPUBLIC LONGEVITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 UNIVERSITY DR E STE 370
BRYAN TX
77802-3485
US

IV. Provider business mailing address

10592 COUNTY ROAD 175
IOLA TX
77861-3617
US

V. Phone/Fax

Practice location:
  • Phone: 979-703-1426
  • Fax:
Mailing address:
  • Phone: 979-703-1426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DENA GASKIN
Title or Position: COO
Credential:
Phone: 979-229-9188