Provider Demographics
NPI:1457044307
Name:LONGEVITY LIVES LLC
Entity Type:Organization
Organization Name:LONGEVITY LIVES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-401-6722
Mailing Address - Street 1:106 BREEZE HILL LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-3609
Mailing Address - Country:US
Mailing Address - Phone:702-325-2119
Mailing Address - Fax:786-401-6041
Practice Address - Street 1:106 BREEZE HILL LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3609
Practice Address - Country:US
Practice Address - Phone:702-325-2119
Practice Address - Fax:786-401-6041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization