Provider Demographics
NPI:1104171206
Name:HEALTHY AGING CLINIC
Entity type:Organization
Organization Name:HEALTHY AGING CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:E
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:302-422-5700
Mailing Address - Street 1:1014 NORTH WALNUT STREET
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-1244
Mailing Address - Country:US
Mailing Address - Phone:302-422-5700
Mailing Address - Fax:302-424-8018
Practice Address - Street 1:1014 NORTH WALNUT STREET
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1244
Practice Address - Country:US
Practice Address - Phone:302-422-5700
Practice Address - Fax:302-424-8018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C48536Medicare UPIN