Provider Demographics
NPI:1518590694
Name:AGELESS MEN'S HEALTH HOLDINGS, PC CA
Entity Type:Organization
Organization Name:AGELESS MEN'S HEALTH HOLDINGS, PC CA
Other - Org Name:AGELESS MEN'S HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TEAH
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-205-3999
Mailing Address - Street 1:3085 FOUNTAINSIDE DR STE 107
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-7842
Mailing Address - Country:US
Mailing Address - Phone:901-757-3643
Mailing Address - Fax:
Practice Address - Street 1:1081 MARKET PL STE 400
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4749
Practice Address - Country:US
Practice Address - Phone:901-757-3643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care