Healthcare Provider Details

I. General information

NPI: 1124264973
Provider Name (Legal Business Name): AGELESS AESTHETIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2008
Last Update Date: 12/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2665 EXECUTIVE PARK DR SUITE 1
WESTON FL
33331-3652
US

IV. Provider business mailing address

2665 EXECUTIVE PARK DR SUITE 1
WESTON FL
33331-3652
US

V. Phone/Fax

Practice location:
  • Phone: 954-454-4900
  • Fax:
Mailing address:
  • Phone: 954-454-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALFONSO RIVIEZZO
Title or Position: BILLING MANAGER
Credential:
Phone: 719-955-9128