Provider Demographics
NPI:1245561828
Name:AGELESS MEN'S HEALTH CA PC
Entity Type:Organization
Organization Name:AGELESS MEN'S HEALTH CA PC
Other - Org Name:
Other - Org Type:
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 1:11633 SAN VINCENTE BLVD
Mailing Address - Street 2:SUITE 214
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049
Mailing Address - Country:US
Mailing Address - Phone:310-979-8378
Mailing Address - Fax:310-979-8379
Practice Address - Street 1:11633 SAN VINCENTE BLVD
Practice Address - Street 2:SUITE 214
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049
Practice Address - Country:US
Practice Address - Phone:310-979-8378
Practice Address - Fax:310-979-8379
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AGELESS MEN'S HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-21
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13875207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty