Provider Demographics
NPI:1114448644
Name:AGELESS MEN'S HEALTH HOLDINGS INC
Entity Type:Organization
Organization Name:AGELESS MEN'S HEALTH HOLDINGS INC
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 1:1729 N CLYBOURN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-6503
Mailing Address - Country:US
Mailing Address - Phone:312-291-8335
Mailing Address - Fax:312-291-8337
Practice Address - Street 1:1729 N CLYBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6503
Practice Address - Country:US
Practice Address - Phone:312-291-8335
Practice Address - Fax:312-291-8337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-06
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty