A Progressive Longevity Center,LLC

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

MA06826400 Issued in NJ

Legal business name

A PROGRESSIVE LONGEVITY CENTER,LLC

Practice address

2555 John F Kennedy Blvd
D
Jersey City, NJ 07304-2165

Phone

(201) 761-0717

Fax

(201) 761-0787

NPI assigned

Jan 21, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Adelia Moustiatse, M.D.

Title

Owner

Phone

(201) 761-0717

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169337600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1237939200000",
    "number": "1568515500",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 WINSTON DR",
            "address_2": "5 HS",
            "city": "CLIFFSIDE PARK",
            "state": "NJ",
            "postal_code": "070103240",
            "telephone_number": "201-761-0717",
            "fax_number": "201-761-0787"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2555 JOHN F KENNEDY BLVD",
            "address_2": "D",
            "city": "JERSEY CITY",
            "state": "NJ",
            "postal_code": "073042165",
            "telephone_number": "201-761-0717",
            "fax_number": "201-761-0787"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "A PROGRESSIVE LONGEVITY CENTER,LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-21",
        "last_updated": "2009-03-25",
        "status": "A",
        "authorized_official_last_name": "MOUSTIATSE",
        "authorized_official_first_name": "ADELIA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "201-761-0717",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": "NJ",
            "license": "MA06826400",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7866305",
            "state": "NJ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Internal Medicine Physician in Jersey City, NJ
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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.