1881369189 NPI number — HEALTH WELLNESS AND LONGEVITY CLINIC LLC

Table of content: (NPI 1881369189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881369189 NPI number — HEALTH WELLNESS AND LONGEVITY CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTH WELLNESS AND LONGEVITY CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
INTERNAL MEDICINE HWL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881369189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2741 DEBARR RD STE C416
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99508-2998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-931-7101
Provider Business Mailing Address Fax Number:
907-274-7855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2741 DEBARR RD STE C416
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99508-2998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-931-7101
Provider Business Practice Location Address Fax Number:
907-274-7855
Provider Enumeration Date:
08/10/2021

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
907-202-9366

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1881369189 . This is a "NPI TYPE 2" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: 1124426754 . This is a "NPI TYPE 1" identifier . This identifiers is of the category "OTHER".




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