Provider Demographics
NPI:1730651589
Name:LONGEVITE HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:LONGEVITE HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:NATALIE
Authorized Official - Last Name:MUCIUS-PENHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-673-8554
Mailing Address - Street 1:14024 WILEY CIR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-5578
Mailing Address - Country:US
Mailing Address - Phone:804-639-8145
Mailing Address - Fax:804-818-2637
Practice Address - Street 1:14024 WILEY CIR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-5578
Practice Address - Country:US
Practice Address - Phone:804-639-8145
Practice Address - Fax:804-818-2637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-18
Last Update Date:2022-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty