Provider Demographics
NPI:1134524788
Name:EAGLE'S LANDING LONGEVITY CENTER
Entity type:Organization
Organization Name:EAGLE'S LANDING LONGEVITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAYLA
Authorized Official - Middle Name:DENEICE
Authorized Official - Last Name:SYLVAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-389-0734
Mailing Address - Street 1:1325 ROCK QUARRY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5088
Mailing Address - Country:US
Mailing Address - Phone:770-389-0734
Mailing Address - Fax:770-389-5364
Practice Address - Street 1:1325 ROCK QUARRY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5088
Practice Address - Country:US
Practice Address - Phone:770-389-0734
Practice Address - Fax:770-389-5364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39958207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11SCGXTMedicare UPIN