Healthcare Provider Details

I. General information

NPI: 1326464868
Provider Name (Legal Business Name): TIMELESS ANTI-AGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W ROUTE 38
MOORESTOWN NJ
08057-3233
US

IV. Provider business mailing address

300 W ROUTE 38
MOORESTOWN NJ
08057-3233
US

V. Phone/Fax

Practice location:
  • Phone: 609-444-7344
  • Fax: 609-257-0666
Mailing address:
  • Phone: 609-444-7344
  • Fax: 609-257-0666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number StateNJ

VIII. Authorized Official

Name: DR. DANIEL DEPRINCE III
Title or Position: OWNER
Credential: D.O.
Phone: 609-444-7344