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General NPI Number Information
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NPI Number | 1922256072
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Entity Type | Organization
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Legal Business Name | ELITE ANTI-AGING AND VEIN CLINIC
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Dates
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Enumeration Date | 09/03/2008
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Last Update Date | 09/03/2008
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Provider Practice Location Address
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Address Line | 5400 N OAK TRFY SUITE 115
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City | KANSAS CITY
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State | MO
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Zip | 64118-4688
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Country | US
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Telephone | 816-453-0017
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Fax | 816-453-0018
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Provider Business Mailing Address
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Address Line | PO BOX 901480
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City | KANSAS CITY
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State | MO
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Zip | 64190-1480
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Country | US
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Telephone | 816-453-0017
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Fax | 816-453-0018
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Authorized Official
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Title or Position | OWNER
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Name | HAROLD ALBERT JOHNSON
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Credential | MD
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Telephone | 816-453-0017
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 2007030787
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License Number State | MO
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