Provider Demographics
NPI:1417315102
Name:HEALTHY AGING ENTERPRISE, LLC
Entity Type:Organization
Organization Name:HEALTHY AGING ENTERPRISE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSTAKLEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-985-9501
Mailing Address - Street 1:10926 BELLE PLAINE BLVD
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-7113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10926 BELLE PLAINE BLVD
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-7113
Practice Address - Country:US
Practice Address - Phone:317-985-9501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty