Provider Demographics
NPI:1588780456
Name:AGELESS ATHLETES
Entity type:Organization
Organization Name:AGELESS ATHLETES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD-HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-565-4024
Mailing Address - Street 1:PO BOX 781
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-0781
Mailing Address - Country:US
Mailing Address - Phone:248-565-4024
Mailing Address - Fax:775-587-3115
Practice Address - Street 1:2000 TOWN CTR STE 1900
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1152
Practice Address - Country:US
Practice Address - Phone:248-565-4024
Practice Address - Fax:775-587-3115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI001148213ES0000X, 174400000X, 213EP1101X
335E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty