Provider Demographics
NPI:1376114322
Name:LONGEVITY CLINICAL LTC ASSOCIATES OF NEW JERSEY
Entity Type:Organization
Organization Name:LONGEVITY CLINICAL LTC ASSOCIATES OF NEW JERSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPPORT TALENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:VINCUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-815-2427
Mailing Address - Street 1:11770 US HIGHWAY 1 STE 102E
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33408-3052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:527 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4722
Practice Address - Country:US
Practice Address - Phone:732-905-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty