Healthcare Provider Details

I. General information

NPI: 1841594892
Provider Name (Legal Business Name): AGE REVERSAL TECHNOLOGIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2011
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N WOODLAWN BLVD
WICHITA KS
67220-2729
US

IV. Provider business mailing address

2600 N WOODLAWN BLVD
WICHITA KS
67220-2729
US

V. Phone/Fax

Practice location:
  • Phone: 316-640-6253
  • Fax: 316-858-2523
Mailing address:
  • Phone: 316-640-6253
  • Fax: 316-858-2523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15-00115
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number15-00115
License Number StateKS

VIII. Authorized Official

Name: MICHAEL N SHAW
Title or Position: OWNER/PRESIDENT
Credential: P.A.
Phone: 316-640-6253