Provider Demographics
NPI:1104322569
Name:AGELESS AESTHETICS OF FLORIDA
Entity type:Organization
Organization Name:AGELESS AESTHETICS OF FLORIDA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-999-5664
Mailing Address - Street 1:1986 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-2533
Mailing Address - Country:US
Mailing Address - Phone:772-999-5664
Mailing Address - Fax:
Practice Address - Street 1:1986 35TH AVE
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-2533
Practice Address - Country:US
Practice Address - Phone:772-999-5664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-04
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0046397OtherMEDICAL LIC