Healthcare Provider Details

I. General information

NPI: 1962759308
Provider Name (Legal Business Name): ANTI-AGING & AESTHETIC MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2012
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 E WILLIAMS ST
APEX NC
27502-2149
US

IV. Provider business mailing address

410 E WILLIAMS ST
APEX NC
27502-2149
US

V. Phone/Fax

Practice location:
  • Phone: 919-362-5910
  • Fax: 919-362-0071
Mailing address:
  • Phone: 919-362-5910
  • Fax: 919-362-0071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number96-00789
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number96-00789
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ARTHUR DAVID ZACCO
Title or Position: PRESIDENT
Credential: D.O.
Phone: 919-362-5910