Provider Demographics
NPI:1477045276
Name:LONGEVITY HOME HEALTHCARE, LLC
Entity Type:Organization
Organization Name:LONGEVITY HOME HEALTHCARE, LLC
Other - Org Name:LONGEVITY HOME HEALTH CARE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GODSON
Authorized Official - Middle Name:CHUKWUMA
Authorized Official - Last Name:EZEJIOFOR
Authorized Official - Suffix:
Authorized Official - Credentials:DHA
Authorized Official - Phone:240-460-3969
Mailing Address - Street 1:3450 LAUREL FORT MEADE RD STE 205
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-2104
Mailing Address - Country:US
Mailing Address - Phone:240-389-5292
Mailing Address - Fax:
Practice Address - Street 1:3450 LAUREL FORT MEADE RD STE 205
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20724-2104
Practice Address - Country:US
Practice Address - Phone:240-389-5292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD100236795Medicaid