Provider Demographics
NPI:1164133716
Name:AGELESS SKIN REJUVENATION LLC
Entity Type:Organization
Organization Name:AGELESS SKIN REJUVENATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:757-707-1231
Mailing Address - Street 1:3352 PRINCESS ANNE RD STE 909
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-2608
Mailing Address - Country:US
Mailing Address - Phone:757-707-1231
Mailing Address - Fax:
Practice Address - Street 1:3352 PRINCESS ANNE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-2608
Practice Address - Country:US
Practice Address - Phone:757-707-1231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty