=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285073791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVE LONGER LABS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2013
-----------------------------------------------------
Last Update Date | 06/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1040 N QUINCY ST SUITE 500
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-828-5227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1040 N QUINCY ST SUITE 500
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GEORGE MINA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-593-4689
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------