Provider Demographics
NPI:1912688748
Name:LONGEVITY PHYSICAL THERAPY
Entity Type:Organization
Organization Name:LONGEVITY PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:636-288-0641
Mailing Address - Street 1:1655 SE UMATILLA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7212
Mailing Address - Country:US
Mailing Address - Phone:636-288-0641
Mailing Address - Fax:
Practice Address - Street 1:1655 SE UMATILLA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7212
Practice Address - Country:US
Practice Address - Phone:636-288-0641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty