Provider Demographics
NPI:1518744861
Name:AGE VICTORIOUSLY LLC
Entity Type:Organization
Organization Name:AGE VICTORIOUSLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:ESSEX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-741-6739
Mailing Address - Street 1:2753 E TAMARISK ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-8997
Mailing Address - Country:US
Mailing Address - Phone:602-741-6739
Mailing Address - Fax:
Practice Address - Street 1:7880 SAN FELIPE ST STE 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-1608
Practice Address - Country:US
Practice Address - Phone:832-377-5968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation