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General NPI Number Information
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NPI Number | 1639743750
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Entity Type | Organization
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Legal Business Name | LONGEVITY CLINICAL LTC ASSOCIATES OF FLORIDA PLLC
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Dates
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Enumeration Date | 05/13/2021
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Last Update Date | 05/14/2021
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Provider Practice Location Address
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Address Line | 4300 ROCK ISLAND RD
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City | LAUDERHILL
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State | FL
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Zip | 33319-4528
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Country | US
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Telephone | 954-485-6144
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Fax |
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Provider Business Mailing Address
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Address Line | 11770 US 1
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City | PALM BEACH GARDENS
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State | FL
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Zip | 33408-3027
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Country | US
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Telephone | 561-815-2427
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Fax |
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Authorized Official
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Title or Position | CLINICAL SUPPORT TALENT SPECIALIST
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Name | DIANE VINCUR
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Credential |
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Telephone | 561-815-2427
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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