Provider Demographics
NPI:1639700776
Name:LONGEVITY HEALTH AND FITNESS, INC.
Entity Type:Organization
Organization Name:LONGEVITY HEALTH AND FITNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:331-248-0695
Mailing Address - Street 1:1150 N 5TH AVE STE B2
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1277
Mailing Address - Country:US
Mailing Address - Phone:331-248-0695
Mailing Address - Fax:331-240-1333
Practice Address - Street 1:1150 N 5TH AVE STE B2
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1277
Practice Address - Country:US
Practice Address - Phone:331-248-0695
Practice Address - Fax:331-240-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-28
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty