MEDICARE: LONGEVITY CLINICAL LTC ASSOCIATES OF NEW JERSEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207QG0300X	Geriatric Medicine (Family Medicine) Physician
2	207Q00000X	Family Medicine Physician
3	363LG0600X	Gerontology Nurse Practitioner
4	363LP2300X	Primary Care Nurse Practitioner

General Provider Information

NPI Number	:	1376114322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGEVITY CLINICAL LTC ASSOCIATES OF NEW JERSEY

Provider Business Mailing Address
First Line	:	11770 US HIGHWAY 1 STE 102E
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33408-3052
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	527 RIVER AVE
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-4722
Country	:	US
Telephone Number	:	732-905-0700
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SUPPORT TALENT SPECIALIST
Name	:	DIANE VINCUR
Credential	:
Telephone Number	:	561-815-2427

Provider Enumeration Date	:	07/09/2021
Last Update Date	:	07/09/2021

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