Provider Demographics
NPI:1912690132
Name:HEALTHY LONGEVITY MEDICAL CENTER
Entity Type:Organization
Organization Name:HEALTHY LONGEVITY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:AIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOULEIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:949-413-1955
Mailing Address - Street 1:552 E CARSON ST APT 409
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:441 E CARSON ST STE K
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-7713
Practice Address - Country:US
Practice Address - Phone:949-413-1955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-01
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty