Provider Demographics
NPI:1538314562
Name:LONGEVITY WELLNESS GROUP
Entity type:Organization
Organization Name:LONGEVITY WELLNESS GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:TRENT
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-323-9222
Mailing Address - Street 1:PO BOX 303460
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-0058
Mailing Address - Country:US
Mailing Address - Phone:512-323-9222
Mailing Address - Fax:512-323-9232
Practice Address - Street 1:4101 MARATHON BOULEVARD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-4026
Practice Address - Country:US
Practice Address - Phone:512-323-9222
Practice Address - Fax:512-323-9232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC30474111NI0900X
TX207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No111NI0900XChiropractic ProvidersChiropractorInternistGroup - Multi-Specialty