Provider Demographics
NPI:1538466578
Name:AGELESS MEN'S HEALTH
Entity Type:Organization
Organization Name:AGELESS MEN'S HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MITIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-757-3643
Mailing Address - Street 1:3650 SOUTH POINTE CIRCLE
Mailing Address - Street 2:SUITE 205-1
Mailing Address - City:LAUGHLIN
Mailing Address - State:NV
Mailing Address - Zip Code:89029-0423
Mailing Address - Country:US
Mailing Address - Phone:702-252-8378
Mailing Address - Fax:702-242-0098
Practice Address - Street 1:3650 SOUTH POINTE CIRCLE
Practice Address - Street 2:SUITE 205-1
Practice Address - City:LAUGHLIN
Practice Address - State:NV
Practice Address - Zip Code:89029-0423
Practice Address - Country:US
Practice Address - Phone:702-252-8378
Practice Address - Fax:702-242-0098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4498174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCH183AOtherMEDICARE PTAN
AZCH183AMedicare UPIN