Provider Demographics
NPI:1568515500
Name:A PROGRESSIVE LONGEVITY CENTER,LLC
Entity Type:Organization
Organization Name:A PROGRESSIVE LONGEVITY CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSTIATSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-761-0717
Mailing Address - Street 1:100 WINSTON DR
Mailing Address - Street 2:5 HS
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-3240
Mailing Address - Country:US
Mailing Address - Phone:201-761-0717
Mailing Address - Fax:201-761-0787
Practice Address - Street 1:2555 JOHN F KENNEDY BLVD
Practice Address - Street 2:D
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-2165
Practice Address - Country:US
Practice Address - Phone:201-761-0717
Practice Address - Fax:201-761-0787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-21
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA06826400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7866305Medicaid
NJ7866305Medicaid
NJ086507Medicare PIN