Provider Demographics
NPI:1376975748
Name:ANTIAGING AND WELLNESS INSTITUTE, PLLC
Entity Type:Organization
Organization Name:ANTIAGING AND WELLNESS INSTITUTE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-947-2873
Mailing Address - Street 1:4141 N GOLDWATER BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3848
Mailing Address - Country:US
Mailing Address - Phone:480-947-2873
Mailing Address - Fax:
Practice Address - Street 1:4141 N GOLDWATER BLVD STE 102
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-3848
Practice Address - Country:US
Practice Address - Phone:480-947-2873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ34602207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty