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General NPI Number Information
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NPI Number | 1245352194
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Entity Type | Organization
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Legal Business Name | LONGEVITY CENTER OF FORT MYERS, INC.
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Dates
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Enumeration Date | 04/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 12621 NEW BRITTANY BLVD BLD 17
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City | FORT MYERS
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State | FL
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Zip | 33907-3631
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Country | US
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Telephone | 239-274-6188
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Fax | 239-274-6186
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Provider Business Mailing Address
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Address Line | 12621 NEW BRITTANY BLVD. BLD 17
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City | FORT MYERS
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State | FL
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Zip | 33907
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Country | US
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Telephone | 239-274-6188
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Fax | 239-274-6186
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | CAROL S LEVEQUE
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Credential | AP
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Telephone | 230-274-6188
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AP 914
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License Number State | FL
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