Provider Demographics
NPI:1215096383
Name:LONGEVITY REHABILITATION CENTER INC
Entity type:Organization
Organization Name:LONGEVITY REHABILITATION CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:ST MARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-978-9750
Mailing Address - Street 1:1515 INDIAN RIVER BLVD
Mailing Address - Street 2:SUITE A135
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960
Mailing Address - Country:US
Mailing Address - Phone:772-978-9750
Mailing Address - Fax:772-978-9748
Practice Address - Street 1:1515 INDIAN RIVER BLVD
Practice Address - Street 2:SUITE A135
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960
Practice Address - Country:US
Practice Address - Phone:772-978-9750
Practice Address - Fax:772-978-9748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC5143261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
K1943Medicare ID - Type Unspecified