Healthcare Provider Details

I. General information

NPI: 1417452699
Provider Name (Legal Business Name): AGEPLAN INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 FAIRVIEW AVE
RATON NM
87740-3523
US

IV. Provider business mailing address

274 FAIRVIEW AVE
RATON NM
87740-3523
US

V. Phone/Fax

Practice location:
  • Phone: 505-980-2584
  • Fax:
Mailing address:
  • Phone: 505-980-2584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. BERT C. DENNIS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-980-2584