=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952919490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGE WELL CONCIERGE MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2020
-----------------------------------------------------
Last Update Date | 07/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18441 TX-105 SUITE B
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-494-9520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 224 LAKE ESTATES DR
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77356-4806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-494-9520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MONICA MILFORD
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 936-494-9520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------