Provider Demographics
NPI:1902153992
Name:AGELESS M.D., LLC
Entity type:Organization
Organization Name:AGELESS M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:SEYEDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-688-2468
Mailing Address - Street 1:2221 N BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22207-2526
Mailing Address - Country:US
Mailing Address - Phone:703-688-2468
Mailing Address - Fax:703-859-7689
Practice Address - Street 1:2221 N BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207-2526
Practice Address - Country:US
Practice Address - Phone:703-688-2468
Practice Address - Fax:703-859-7689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-08
Last Update Date:2015-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232169261QC1800X, 261QV0200X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA