Provider Demographics
NPI:1467723486
Name:LONGEVITY MEDICAL LLC
Entity Type:Organization
Organization Name:LONGEVITY MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DNP,FNP-BC,PMHNP-BC
Authorized Official - Phone:901-440-6045
Mailing Address - Street 1:PO BOX 4355
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38088-4355
Mailing Address - Country:US
Mailing Address - Phone:901-440-6045
Mailing Address - Fax:901-459-3373
Practice Address - Street 1:1355 B LYNNFIELD RD
Practice Address - Street 2:STE 205
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5801
Practice Address - Country:US
Practice Address - Phone:901-440-6045
Practice Address - Fax:901-459-3373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN14184163WG0600X, 163WP0808X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No163WG0600XNursing Service ProvidersRegistered NurseGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1527059Medicaid
TN1527059Medicaid