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General NPI Number Information
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NPI Number | 1730774076
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Entity Type | Organization
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Legal Business Name | LONGEVITA CLINIC, A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 03/09/2021
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Last Update Date | 02/24/2023
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Provider Practice Location Address
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Address Line | 21757 DEVONSHIRE ST STE 1
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City | CHATSWORTH
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State | CA
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Zip | 91311-2975
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Country | US
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Telephone | 805-630-7149
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Fax | 888-981-8739
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Provider Business Mailing Address
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Address Line | 21757 DEVONSHIRE ST STE 1
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City | CHATSWORTH
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State | CA
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Zip | 91311-2975
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Country | US
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Telephone | 818-678-9875
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Fax | 747-200-2589
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Authorized Official
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Title or Position | SECRETARY
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Name | DR. RICHARD PARK
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Credential | MD
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Telephone | 805-368-1293
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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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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