Provider Demographics
NPI:1164949897
Name:LONGEVITY PERFORMANCE & PHYSICAL THERAPY
Entity Type:Organization
Organization Name:LONGEVITY PERFORMANCE & PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGAT
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, ATC, MS, CSCS
Authorized Official - Phone:440-667-9947
Mailing Address - Street 1:560 SCENIC LN
Mailing Address - Street 2:
Mailing Address - City:SEVEN HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44131-3867
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 SCENIC LN
Practice Address - Street 2:
Practice Address - City:SEVEN HILLS
Practice Address - State:OH
Practice Address - Zip Code:44131-3867
Practice Address - Country:US
Practice Address - Phone:440-667-9947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH012594261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy