Healthcare Provider Details

I. General information

NPI: 1235975202
Provider Name (Legal Business Name): AGELESS WOMEN'S HEALTH ID LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3875 E OVERLAND RD STE 108
MERIDIAN ID
83642-9047
US

IV. Provider business mailing address

3875 E OVERLAND RD STE 108
MERIDIAN ID
83642-9047
US

V. Phone/Fax

Practice location:
  • Phone: 208-268-5592
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TEAH PHILLIPS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 901-205-3999