Provider Demographics
NPI:1083052864
Name:AGELESS MEN'S HEALTH CA PPC
Entity Type:Organization
Organization Name:AGELESS MEN'S HEALTH CA PPC
Other - Org Name:AGELESS MEN'S HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TEAH
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-205-3999
Mailing Address - Street 1:12501 SEAL BEACH BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-2755
Mailing Address - Country:US
Mailing Address - Phone:949-854-8378
Mailing Address - Fax:949-854-8379
Practice Address - Street 1:12501 SEAL BEACH BLVD STE 220
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-2755
Practice Address - Country:US
Practice Address - Phone:562-685-9367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty