Healthcare Provider Details

I. General information

NPI: 1124322474
Provider Name (Legal Business Name): AGELESS MEN'S HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2010
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7111 SOUTHCREST PKWY SUITE 109
SOUTHAVEN MS
38671-4850
US

IV. Provider business mailing address

7111 SOUTHCREST PKWY SUITE 109
SOUTHAVEN MS
38671-4850
US

V. Phone/Fax

Practice location:
  • Phone: 901-522-6745
  • Fax: 901-522-6748
Mailing address:
  • Phone: 901-522-6745
  • Fax: 901-522-6748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AMANDA WILKINSON
Title or Position: BUSINESS OPERATIONS DIRECTOR
Credential:
Phone: 702-818-0446