=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154287639
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTYVILLE LONGEVITY AND LIGHT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2025
-----------------------------------------------------
Last Update Date | 12/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1880 W WINCHESTER RD STE 102
-----------------------------------------------------
City | LIBERTYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60048-5321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-717-8357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1880 W WINCHESTER RD STE 102
-----------------------------------------------------
City | LIBERTYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60048-5321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-717-8357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JUSTIN D SEYL
-----------------------------------------------------
Credential | CERTIFIED HBOT TECH
-----------------------------------------------------
Telephone | 615-336-6506
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 405300000X
-----------------------------------------------------
Taxonomy Name | Prevention Professional
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------