=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669620175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ANTI-AGING CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2008
-----------------------------------------------------
Last Update Date | 09/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2708 S SEACREST BLVD
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33435-7502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-733-6768
-----------------------------------------------------
Fax | 561-733-1860
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2708 S SEACREST BLVD
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33435-7502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-733-6768
-----------------------------------------------------
Fax | 561-733-1860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. LYUBA STANISLAVOVN ZHIGALINA
-----------------------------------------------------
Credential | PHYSICAL THERAPIST
-----------------------------------------------------
Telephone | 561-733-6768
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | MA29681
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------