Provider Demographics
NPI:1235581430
Name:AGELESS MEN'S HEALTH HOLDINGS, PC CA
Entity Type:Organization
Organization Name:AGELESS MEN'S HEALTH HOLDINGS, PC CA
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 1:1847 VICTORY BLVD
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3550
Mailing Address - Country:US
Mailing Address - Phone:212-837-1946
Mailing Address - Fax:212-837-1908
Practice Address - Street 1:78 TODT HILL RD STE 205
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-4528
Practice Address - Country:US
Practice Address - Phone:212-837-1946
Practice Address - Fax:212-837-1908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty