Provider Demographics
NPI:1518392380
Name:AGELESS MEDICAL SPA - CLINIC
Entity Type:Organization
Organization Name:AGELESS MEDICAL SPA - CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARILA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:915-929-6369
Mailing Address - Street 1:3961 E LOHMAN AVE
Mailing Address - Street 2:SUITE 12
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8269
Mailing Address - Country:US
Mailing Address - Phone:575-521-4888
Mailing Address - Fax:575-521-4888
Practice Address - Street 1:3961 E LOHMAN AVE
Practice Address - Street 2:SUITE 12
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8269
Practice Address - Country:US
Practice Address - Phone:575-521-4888
Practice Address - Fax:575-521-4888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-11
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP02129363LF0000X
NMCNP02155363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty