Provider Demographics
NPI:1851126932
Name:AGELESS REWIND LLC
Entity type:Organization
Organization Name:AGELESS REWIND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:WRAZIEN
Authorized Official - Suffix:
Authorized Official - Credentials:AGNP
Authorized Official - Phone:813-460-6440
Mailing Address - Street 1:1911 BLUE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34691-7849
Mailing Address - Country:US
Mailing Address - Phone:813-360-1806
Mailing Address - Fax:
Practice Address - Street 1:1911 BLUE RIVER RD
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34691-7849
Practice Address - Country:US
Practice Address - Phone:727-320-7313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-06
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty