Provider Demographics
NPI:1740512961
Name:ARLINGTON LONGEVITY INSTITUTE
Entity type:Organization
Organization Name:ARLINGTON LONGEVITY INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRILL
Authorized Official - Middle Name:K
Authorized Official - Last Name:HAWS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:847-549-1424
Mailing Address - Street 1:655 CAMINO DE LOS MARES STE 117
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2809
Mailing Address - Country:US
Mailing Address - Phone:949-391-0464
Mailing Address - Fax:
Practice Address - Street 1:655 CAMINO DE LOS MARES STE 117
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2809
Practice Address - Country:US
Practice Address - Phone:949-391-0464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARLINGTON LONGEVITY INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-14
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360731002083P0011X, 261QP2300X
261Q00000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL788850OtherMEDICARE NON-SPECIFIED NUMBER
IL788850OtherMEDICARE NON-SPECIFIED NUMBER