Provider Demographics
NPI:1699599514
Name:LONGEVITY PT & WELLNESS LLC
Entity type:Organization
Organization Name:LONGEVITY PT & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:801-636-3676
Mailing Address - Street 1:4319 N GRANITE REEF RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-2832
Mailing Address - Country:US
Mailing Address - Phone:801-636-3676
Mailing Address - Fax:
Practice Address - Street 1:4448 E MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-7916
Practice Address - Country:US
Practice Address - Phone:480-696-3545
Practice Address - Fax:480-696-5788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty