Healthcare Provider Details

I. General information

NPI: 1518392380
Provider Name (Legal Business Name): AGELESS MEDICAL SPA - CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3961 E LOHMAN AVE SUITE 12
LAS CRUCES NM
88011-8269
US

IV. Provider business mailing address

3961 E LOHMAN AVE SUITE 12
LAS CRUCES NM
88011-8269
US

V. Phone/Fax

Practice location:
  • Phone: 575-521-4888
  • Fax: 575-521-4888
Mailing address:
  • Phone: 575-521-4888
  • Fax: 575-521-4888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP02129
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberCNP02155
License Number StateNM

VIII. Authorized Official

Name: MISS MARILA TAYLOR
Title or Position: OWNER
Credential: NP
Phone: 915-929-6369