Healthcare Provider Details

I. General information

NPI: 1891077624
Provider Name (Legal Business Name): AGE WELL SENIOR SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2011
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24300 EL TORO RD BLDG. A, SUITE 2000
LAGUNA WOODS CA
92637-2737
US

IV. Provider business mailing address

24300 EL TORO RD BLDG. A, SUITE 2000
LAGUNA WOODS CA
92637-2737
US

V. Phone/Fax

Practice location:
  • Phone: 949-855-8033
  • Fax: 949-855-8025
Mailing address:
  • Phone: 949-855-8033
  • Fax: 949-855-8025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberCA161788
License Number StateCA

VIII. Authorized Official

Name: DR. MARILYN L. DITTY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 949-855-8033