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General NPI Number Information
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NPI Number | 1013286533
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Entity Type | Organization
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Legal Business Name | THE ANTI-AGING AND WELLNESS CENTER
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Dates
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Enumeration Date | 12/29/2011
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Last Update Date | 12/29/2011
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Provider Practice Location Address
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Address Line | 655 LAKE HARBOUR DR STE 900
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City | RIDGELAND
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State | MS
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Zip | 39157-4355
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Country | US
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Telephone | 601-707-5171
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Fax |
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Provider Business Mailing Address
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Address Line | 311 FEATHER GLN
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City | RIDGELAND
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State | MS
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Zip | 39157-8703
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Country | US
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Telephone | 601-421-4808
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. DONALD RAY BONNER
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Credential | D.O.
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Telephone | 601-421-4808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 960070
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License Number State | MS
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