Healthcare Provider Details

I. General information

NPI: 1558937730
Provider Name (Legal Business Name): AGELESS MEDICA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11841 MASON MONTGOMERY RD
CINCINNATI OH
45249-1748
US

IV. Provider business mailing address

11841 MASON MONTGOMERY RD
CINCINNATI OH
45249-1748
US

V. Phone/Fax

Practice location:
  • Phone: 937-544-4020
  • Fax: 937-544-4009
Mailing address:
  • Phone: 937-544-4020
  • Fax: 937-544-4009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHRI RAO
Title or Position: PRESIDENT
Credential: MD
Phone: 937-544-4020