Provider Demographics
NPI:1245352194
Name:LONGEVITY CENTER OF FORT MYERS, INC.
Entity type:Organization
Organization Name:LONGEVITY CENTER OF FORT MYERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEVEQUE
Authorized Official - Suffix:
Authorized Official - Credentials:AP
Authorized Official - Phone:230-274-6188
Mailing Address - Street 1:12621 NEW BRITTANY BLVD.
Mailing Address - Street 2:BLD 17
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907
Mailing Address - Country:US
Mailing Address - Phone:239-274-6188
Mailing Address - Fax:239-274-6186
Practice Address - Street 1:12621 NEW BRITTANY BLVD
Practice Address - Street 2:BLD 17
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3631
Practice Address - Country:US
Practice Address - Phone:239-274-6188
Practice Address - Fax:239-274-6186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 914171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty