Provider Demographics
NPI:1528244811
Name:CENTER FOR LONGEVITY AND WELLNESS
Entity type:Organization
Organization Name:CENTER FOR LONGEVITY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:ROBERTS
Authorized Official - Last Name:SCHACHERL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-885-7360
Mailing Address - Street 1:3601 HOUMA BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-4326
Mailing Address - Country:US
Mailing Address - Phone:504-885-7360
Mailing Address - Fax:504-885-1360
Practice Address - Street 1:3601 HOUMA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-4326
Practice Address - Country:US
Practice Address - Phone:504-885-7360
Practice Address - Fax:504-885-1360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012129207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5CF03OtherMEDICARE
LAB60653Medicare UPIN