Healthcare Provider Details

I. General information

NPI: 1316780216
Provider Name (Legal Business Name): AGELESS RADIANCE BEAUTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 HIDDEN COURT RD
HOLLYWOOD FL
33023-7466
US

IV. Provider business mailing address

149 HIDDEN COURT RD
HOLLYWOOD FL
33023-7466
US

V. Phone/Fax

Practice location:
  • Phone: 786-246-5268
  • Fax:
Mailing address:
  • Phone: 786-699-0614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: CATHELINE MONESTIME
Title or Position: MEMBER
Credential:
Phone: 786-699-0614