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General NPI Number Information
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NPI Number | 1912690132
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Entity Type | Organization
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Legal Business Name | HEALTHY LONGEVITY MEDICAL CENTER
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Dates
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Enumeration Date | 06/01/2023
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Last Update Date | 06/08/2023
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Provider Practice Location Address
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Address Line | 441 E CARSON ST STE K
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City | CARSON
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State | CA
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Zip | 90745-7713
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Country | US
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Telephone | 949-413-1955
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Fax |
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Provider Business Mailing Address
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Address Line | 552 E CARSON ST APT 409
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City | CARSON
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State | CA
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Zip | 90745-2890
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MISS AIDA SOULEIMAN
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Credential | NP
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Telephone | 949-413-1955
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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