Provider Demographics
NPI:1023558210
Name:TUSTIN LONGEVITY CENTER
Entity Type:Organization
Organization Name:TUSTIN LONGEVITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ELLITHORPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-544-1521
Mailing Address - Street 1:13422 NEWPORT AVE
Mailing Address - Street 2:SUITE L
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3746
Mailing Address - Country:US
Mailing Address - Phone:714-544-1521
Mailing Address - Fax:
Practice Address - Street 1:13422 NEWPORT AVE
Practice Address - Street 2:SUITE L
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3746
Practice Address - Country:US
Practice Address - Phone:714-544-1521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83575305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG83575Medicare UPIN