Provider Demographics
NPI:1003276049
Name:LONGEVITY PT
Entity Type:Organization
Organization Name:LONGEVITY PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:843-906-7169
Mailing Address - Street 1:5524 GALLATIN LN
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420-6803
Mailing Address - Country:US
Mailing Address - Phone:843-906-7169
Mailing Address - Fax:
Practice Address - Street 1:5524 GALLATIN LN
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-6803
Practice Address - Country:US
Practice Address - Phone:843-906-7169
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4916251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health