Provider Demographics
NPI:1063765147
Name:AGELESS MEN'S HEALTH, PLLC
Entity type:Organization
Organization Name:AGELESS MEN'S HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-757-3643
Mailing Address - Street 1:4970 W HIGHWAY 290
Mailing Address - Street 2:SUITE 470
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-6748
Mailing Address - Country:US
Mailing Address - Phone:512-892-1900
Mailing Address - Fax:512-892-1904
Practice Address - Street 1:4970 W HIGHWAY 290
Practice Address - Street 2:SUITE 470
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-6748
Practice Address - Country:US
Practice Address - Phone:512-892-1900
Practice Address - Fax:512-892-1904
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AGELESS MEN'S HEALTH HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty