Provider Demographics
NPI:1154564383
Name:AEON HEALTH, INC.
Entity type:Organization
Organization Name:AEON HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:WILLINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-526-8600
Mailing Address - Street 1:4809 COLE AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-3553
Mailing Address - Country:US
Mailing Address - Phone:214-526-8600
Mailing Address - Fax:214-443-3897
Practice Address - Street 1:4809 COLE AVE STE 110
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-3553
Practice Address - Country:US
Practice Address - Phone:214-526-8600
Practice Address - Fax:214-443-3897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0463204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty