Provider Demographics
NPI:1528600020
Name:LONGEVITY WELLNESS CLINIC OF ARIZONA
Entity Type:Organization
Organization Name:LONGEVITY WELLNESS CLINIC OF ARIZONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-453-1367
Mailing Address - Street 1:PO BOX 10456
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85271-0456
Mailing Address - Country:US
Mailing Address - Phone:480-453-1367
Mailing Address - Fax:
Practice Address - Street 1:3920 S ALMA SCHOOL RD STE 8
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-4511
Practice Address - Country:US
Practice Address - Phone:480-453-1367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center