Healthcare Provider Details

I. General information

NPI: 1972889988
Provider Name (Legal Business Name): LONGEVITY URGENT CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 WEST MCCART ST STE B
KRUM TX
76249
US

IV. Provider business mailing address

PO BOX 798
KRUM TX
76249-0798
US

V. Phone/Fax

Practice location:
  • Phone: 940-390-9709
  • Fax: 940-482-1775
Mailing address:
  • Phone: 940-320-9709
  • Fax: 940-482-1775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number778411
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberF1170
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberK7643
License Number StateTX

VIII. Authorized Official

Name: MR. ADRIAN C JONES
Title or Position: NURSE PRACTITIONER
Credential: NP-C
Phone: 940-320-9709