Provider Demographics
NPI:1871224980
Name:LONGLIVE HEALTHCARE LLC
Entity Type:Organization
Organization Name:LONGLIVE HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:MOON
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-633-5900
Mailing Address - Street 1:10304 EATON PL STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2221
Mailing Address - Country:US
Mailing Address - Phone:571-633-5900
Mailing Address - Fax:
Practice Address - Street 1:10304 EATON PL STE 100
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2221
Practice Address - Country:US
Practice Address - Phone:571-633-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-20
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty