Provider Demographics
NPI:1407422447
Name:LONGEVITY CLINICAL LTC ASSOCIATES OF ILLINOIS PLLC
Entity Type:Organization
Organization Name:LONGEVITY CLINICAL LTC ASSOCIATES OF ILLINOIS PLLC
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:561-444-0788
Mailing Address - Fax:
Practice Address - Street 1:6300 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1702
Practice Address - Country:US
Practice Address - Phone:773-973-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
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