Provider Demographics
NPI:1508233693
Name:YOUTHFUL LIVING LLC
Entity Type:Organization
Organization Name:YOUTHFUL LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:HUXLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:623-972-1840
Mailing Address - Street 1:PO BOX 12228
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85318-2228
Mailing Address - Country:US
Mailing Address - Phone:623-972-1840
Mailing Address - Fax:623-972-1855
Practice Address - Street 1:10222 W COGGINS DR
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3407
Practice Address - Country:US
Practice Address - Phone:623-972-1840
Practice Address - Fax:623-972-1855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4547207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty