Provider Demographics
NPI:1285455527
Name:LONGEVITY MEDICAL INSTITUTE LLC
Entity type:Organization
Organization Name:LONGEVITY MEDICAL INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:702-401-8930
Mailing Address - Street 1:4521 SAN FELIPE ST UNIT 2902
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-3388
Mailing Address - Country:US
Mailing Address - Phone:702-401-8930
Mailing Address - Fax:
Practice Address - Street 1:32 VILLAS DEL MAR
Practice Address - Street 2:
Practice Address - City:SAN JOSE DEL CABO
Practice Address - State:BAJA CALIFORNIA SUR
Practice Address - Zip Code:23406
Practice Address - Country:MX
Practice Address - Phone:702-401-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Single Specialty