Basic Information
| Provider Information | |||||||||
| NPI: | 1730774076 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONGEVITA CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21757 DEVONSHIRE ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913112975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056307149 | ||||||||
| FaxNumber: | 8889818739 | ||||||||
| Practice Location | |||||||||
| Address1: | 21757 DEVONSHIRE ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913112975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056307149 | ||||||||
| FaxNumber: | 8889818739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2021 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | PARK | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 8056307149 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.