Healthcare Provider Details

I. General information

NPI: 1841639648
Provider Name (Legal Business Name): AGELESS MEN'S HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 COMMON WEALTH BLVD
TUPELO MS
38801
US

IV. Provider business mailing address

3085 FOUNTAINSIDE DR SUITE 108
GERMANTOWN TN
38138-7842
US

V. Phone/Fax

Practice location:
  • Phone: 901-757-3643
  • Fax: 901-757-7762
Mailing address:
  • Phone: 901-757-3643
  • Fax: 901-757-7762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

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