Provider Demographics
NPI:1679923668
Name:INTENTIONAL LONGEVITY, INC.
Entity type:Organization
Organization Name:INTENTIONAL LONGEVITY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ILISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHCA, LCAS, CSI
Authorized Official - Phone:740-648-6093
Mailing Address - Street 1:370 N LOUISIANA AVE STE D3
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-3641
Mailing Address - Country:US
Mailing Address - Phone:828-412-3688
Mailing Address - Fax:828-412-3689
Practice Address - Street 1:370 N LOUISIANA AVE
Practice Address - Street 2:SUITE D3 & D4
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-3600
Practice Address - Country:US
Practice Address - Phone:828-412-3688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-21
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty