Provider Demographics
NPI:1922438886
Name:LONGEVITY MANAGEMENT GROUP, LLC
Entity Type:Organization
Organization Name:LONGEVITY MANAGEMENT GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODBECK
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:760-242-8900
Mailing Address - Street 1:15982 QUANTICO RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1382
Mailing Address - Country:US
Mailing Address - Phone:760-242-8900
Mailing Address - Fax:
Practice Address - Street 1:15982 QUANTICO RD
Practice Address - Street 2:SUITE D
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1382
Practice Address - Country:US
Practice Address - Phone:760-242-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 26869174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty