Provider Demographics
NPI:1124726377
Name:LONGEVITY AND PERFORMANCE CLINIC, PLLC
Entity type:Organization
Organization Name:LONGEVITY AND PERFORMANCE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:REITER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-442-9005
Mailing Address - Street 1:64 ABBOTTSFORD DR
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-9756
Mailing Address - Country:US
Mailing Address - Phone:336-442-9005
Mailing Address - Fax:
Practice Address - Street 1:2475 HILLCREST CENTER CIR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3048
Practice Address - Country:US
Practice Address - Phone:336-754-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-17
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes283X00000XHospitalsRehabilitation Hospital
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty