1568515500 NPI number — A PROGRESSIVE LONGEVITY CENTER,LLC

Table of content: (NPI 1568515500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568515500 NPI number — A PROGRESSIVE LONGEVITY CENTER,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A PROGRESSIVE LONGEVITY CENTER,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:
Provider Other Organization Name Type Code:
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:
1568515500
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 WINSTON DR
Provider Second Line Business Mailing Address:
5 HS
Provider Business Mailing Address City Name:
CLIFFSIDE PARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07010-3240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-761-0717
Provider Business Mailing Address Fax Number:
201-761-0787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2555 JOHN F KENNEDY BLVD
Provider Second Line Business Practice Location Address:
D
Provider Business Practice Location Address City Name:
JERSEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07304-2165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-761-0717
Provider Business Practice Location Address Fax Number:
201-761-0787
Provider Enumeration Date:
01/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOUSTIATSE
Authorized Official First Name:
ADELIA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
201-761-0717

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MA06826400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7866305 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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