Healthcare Provider Details

I. General information

NPI: 1588780456
Provider Name (Legal Business Name): AGELESS ATHLETES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 TOWN CTR STE 1900
SOUTHFIELD MI
48075-1152
US

IV. Provider business mailing address

PO BOX 781
SOUTHFIELD MI
48037-0781
US

V. Phone/Fax

Practice location:
  • Phone: 248-565-4024
  • Fax: 775-587-3115
Mailing address:
  • Phone: 248-565-4024
  • Fax: 775-587-3115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number001148
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number001148
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number001148
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. DENISE BRADFORD-HENRY
Title or Position: DIRECTOR
Credential: DPM
Phone: 248-565-4024