Healthcare Provider Details

I. General information

NPI: 1245798461
Provider Name (Legal Business Name): AGELESS BODY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E HALLANDALE BEACH BLVD STE 406
HALLANDALE BEACH FL
33009-4837
US

IV. Provider business mailing address

2500 E HALLANDALE BEACH BLVD STE 406
HALLANDALE BEACH FL
33009-4837
US

V. Phone/Fax

Practice location:
  • Phone: 954-990-0302
  • Fax: 954-908-7101
Mailing address:
  • Phone: 954-990-0302
  • Fax: 954-908-7101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: INNA S TRAKHTENBERG
Title or Position: CEO - CHIROPRACTOR
Credential: DC
Phone: 954-990-0302