Provider Demographics
NPI:1508227216
Name:TEAM ANTI-AGING CENTER INC
Entity Type:Organization
Organization Name:TEAM ANTI-AGING CENTER INC
Other - Org Name:TEAM DOCTORS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:STOXEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-735-5200
Mailing Address - Street 1:222 W ONTARIO ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3652
Mailing Address - Country:US
Mailing Address - Phone:773-735-5200
Mailing Address - Fax:773-735-8656
Practice Address - Street 1:222 W ONTARIO ST
Practice Address - Street 2:SUITE 503
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3652
Practice Address - Country:US
Practice Address - Phone:773-735-5200
Practice Address - Fax:773-735-8656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005767261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038005767OtherILLINOIS STATE LICENSE NUMBER