Provider Demographics
NPI:1487541405
Name:LONGEVITY HEALTHCARE LLC
Entity type:Organization
Organization Name:LONGEVITY HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:NIMENE
Authorized Official - Last Name:KOFA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:404-921-4511
Mailing Address - Street 1:906 RIVER ROCK DR # 30188
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-5337
Mailing Address - Country:US
Mailing Address - Phone:404-921-4511
Mailing Address - Fax:
Practice Address - Street 1:906 RIVER ROCK DR # 30188
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-5337
Practice Address - Country:US
Practice Address - Phone:404-921-4511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health