Provider Demographics
NPI:1376188540
Name:BROOKLYN LONGEVITY NUTRITION, PLLC
Entity Type:Organization
Organization Name:BROOKLYN LONGEVITY NUTRITION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENG
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:646-875-1655
Mailing Address - Street 1:2054 BAY RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-4629
Mailing Address - Country:US
Mailing Address - Phone:646-875-1655
Mailing Address - Fax:
Practice Address - Street 1:2054 BAY RIDGE AVE BSMT
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-4629
Practice Address - Country:US
Practice Address - Phone:646-875-1655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-12
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center