Provider Demographics
NPI:1376257386
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 1:1920 W 250 N STE 1
Mailing Address - Street 2:
Mailing Address - City:MARRIOTT SLATERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84404-9234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1920 W 250 N STE 1
Practice Address - Street 2:
Practice Address - City:MARRIOTT SLATERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84404-9234
Practice Address - Country:US
Practice Address - Phone:801-878-7411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty