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General NPI Number Information
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NPI Number | 1023523750
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Entity Type | Organization
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Legal Business Name | AGELESS CENTER LLC
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Dates
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Enumeration Date | 12/04/2017
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Last Update Date | 12/04/2017
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Provider Practice Location Address
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Address Line | 201 PENNSYLVANIA PKWY STE 201
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City | INDIANAPOLIS
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State | IN
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Zip | 46280-1393
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Country | US
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Telephone | 317-528-9119
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Fax |
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Provider Business Mailing Address
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Address Line | 201 PENNSYLVANIA PKWY STE 201
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City | INDIANAPOLIS
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State | IN
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Zip | 46280-1393
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Country | US
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Telephone | 317-528-9119
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | WYATT HORSLEY
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Credential | MD
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Telephone | 317-528-9119
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RB0002X
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Taxonomy Name | Obesity Medicine (Internal Medicine) Physician
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License Number | 01076865A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 2083B0002X
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Taxonomy Name | Obesity Medicine (Preventive Medicine) Physician
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License Number | 01076865A
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License Number State | IN
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