Provider Demographics
NPI:1881369189
Name:HEALTH WELLNESS AND LONGEVITY CLINIC LLC
Entity type:Organization
Organization Name:HEALTH WELLNESS AND LONGEVITY CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-202-9366
Mailing Address - Street 1:2741 DEBARR RD STE C416
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2998
Mailing Address - Country:US
Mailing Address - Phone:907-931-7101
Mailing Address - Fax:907-274-7855
Practice Address - Street 1:2741 DEBARR RD STE C416
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2998
Practice Address - Country:US
Practice Address - Phone:907-931-7101
Practice Address - Fax:907-274-7855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1881369189OtherNPI TYPE 2
1124426754OtherNPI TYPE 1