Healthcare Provider Details

I. General information

NPI: 1285073791
Provider Name (Legal Business Name): LIVE LONGER LABS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 N QUINCY ST SUITE 500
ARLINGTON VA
22201
US

IV. Provider business mailing address

1040 N QUINCY ST SUITE 500
ARLINGTON VA
22201
US

V. Phone/Fax

Practice location:
  • Phone: 703-828-5227
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: GEORGE MINA
Title or Position: PRESIDENT
Credential:
Phone: 917-593-4689