Provider Demographics
NPI:1124322474
Name:AGELESS MEN'S HEALTH, LLC
Entity type:Organization
Organization Name:AGELESS MEN'S HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-818-0446
Mailing Address - Street 1:7111 SOUTHCREST PKWY
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-4850
Mailing Address - Country:US
Mailing Address - Phone:901-522-6745
Mailing Address - Fax:901-522-6748
Practice Address - Street 1:7111 SOUTHCREST PKWY
Practice Address - Street 2:SUITE 109
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4850
Practice Address - Country:US
Practice Address - Phone:901-522-6745
Practice Address - Fax:901-522-6748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty