Provider Demographics
NPI:1730774076
Name:LONGEVITA CLINIC, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:LONGEVITA CLINIC, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-368-1293
Mailing Address - Street 1:21757 DEVONSHIRE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-2975
Mailing Address - Country:US
Mailing Address - Phone:818-678-9875
Mailing Address - Fax:747-200-2589
Practice Address - Street 1:21757 DEVONSHIRE ST STE 1
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-2975
Practice Address - Country:US
Practice Address - Phone:805-630-7149
Practice Address - Fax:888-981-8739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-09
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty