Provider Demographics
NPI:1639043755
Name:RADIANT LONGEVITY CARE
Entity type:Organization
Organization Name:RADIANT LONGEVITY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RALPHAEL
Authorized Official - Middle Name:KORBLA
Authorized Official - Last Name:KUKUBOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-989-9777
Mailing Address - Street 1:140 E RIDGEWOOD AVE STE 415
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3915
Mailing Address - Country:US
Mailing Address - Phone:201-989-9777
Mailing Address - Fax:155-136-1972
Practice Address - Street 1:140 E RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3917
Practice Address - Country:US
Practice Address - Phone:201-989-9777
Practice Address - Fax:155-136-1972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-01
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health