# LONGEVITY CLINICAL LTC ASSOCIATES OF GEORGIA, PC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1699469668
- **Authorized official:** DIANE L VINCUR (LWC PRACTICE MANAGER)
- **Authorized official phone:** (561) 815-2427

## Contact information

- **Practice address:** 1040 CROWN POINTE PKWY STE 600, ATLANTA, GA 30338-4741
- **Practice address phone:** (561) 815-2427
- **Mailing address:** 11780 US HIGHWAY 1 STE N107, NORTH PALM BEACH, FL 33408-3007

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207QG0300X | Geriatric Medicine (Family Medicine) Physician | — | NULL | — |
| 207QG0300X | Geriatric Medicine (Family Medicine) Physician | — | — | — |
| 363LG0600X | Gerontology Nurse Practitioner | — | NULL | — |
| 363LG0600X | Gerontology Nurse Practitioner | — | — | — |
| 363LP2300X | Primary Care Nurse Practitioner | — | NULL | — |
| 363LP2300X | Primary Care Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 06/05/2023
- **Last updated:** 06/05/2023