Provider Demographics
NPI:1093174088
Name:INTENTIONAL LONGEVITY, INC.
Entity Type:Organization
Organization Name:INTENTIONAL LONGEVITY, INC.
Other - Org Name:THE CENTER FOR SPIRITUAL EMERGENCE & KATHAROS SANCTUARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GRADY
Authorized Official - Middle Name:BRAXTON
Authorized Official - Last Name:JEFFERYS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:828-273-1643
Mailing Address - Street 1:370 N LOUISIANA AVE
Mailing Address - Street 2:SUITE D3
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-3600
Mailing Address - Country:US
Mailing Address - Phone:828-272-1643
Mailing Address - Fax:
Practice Address - Street 1:370 N LOUISIANA AVE
Practice Address - Street 2:SUITE D3
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-3600
Practice Address - Country:US
Practice Address - Phone:828-272-1643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QM0850X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder