Basic Information
| Provider Information | |||||||||
| NPI: | 1972269793 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONGEVITY CLINICAL LTC ASSOCIATES OF COLORADO PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11770 US HIGHWAY 1 STE 102E | ||||||||
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| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334083052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133992607 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12136 W BAYAUD AVE | ||||||||
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| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802282115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032383838 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2021 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | VINCUR | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL SUPPORT TALENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5618152427 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
No ID Information.