Healthcare Provider Details

I. General information

NPI: 1760749634
Provider Name (Legal Business Name): AGELESS MEN'S HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2012
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 BROADWAY STE 1804
NEW YORK NY
10006-2560
US

IV. Provider business mailing address

65 BROADWAY STE 1804
NEW YORK NY
10006-2560
US

V. Phone/Fax

Practice location:
  • Phone: 212-430-6677
  • Fax: 212-430-6678
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number22 634573
License Number StateNY

VIII. Authorized Official

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