Healthcare Provider Details

I. General information

NPI: 1902153992
Provider Name (Legal Business Name): AGELESS M.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 10/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 N BUCHANAN ST
ARLINGTON VA
22207-2526
US

IV. Provider business mailing address

2221 N BUCHANAN ST
ARLINGTON VA
22207-2526
US

V. Phone/Fax

Practice location:
  • Phone: 703-688-2468
  • Fax: 703-859-7689
Mailing address:
  • Phone: 703-688-2468
  • Fax: 703-859-7689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number0101232169
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number0101232169
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0101232169
License Number StateVA

VIII. Authorized Official

Name: MR. SHAI SEYEDAN
Title or Position: PARTNER
Credential:
Phone: 703-688-2468