Healthcare Provider Details

I. General information

NPI: 1033829478
Provider Name (Legal Business Name): AGELESS HEALTH GROUP, A PROFESSIONAL CORP NURSING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 E E ST
ONTARIO CA
91764-3820
US

IV. Provider business mailing address

703 E E ST
ONTARIO CA
91764-3820
US

V. Phone/Fax

Practice location:
  • Phone: 909-435-4707
  • Fax:
Mailing address:
  • Phone: 909-435-4707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SONIA YENITZA RODRIGUES
Title or Position: CEO
Credential: FNP-C
Phone: 909-435-4707