Provider Demographics
NPI:1588030100
Name:AGELESS CENTER OF REGENERATIVE & WELLNESS MEDICINE
Entity Type:Organization
Organization Name:AGELESS CENTER OF REGENERATIVE & WELLNESS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:678-364-8414
Mailing Address - Street 1:1000 COMMERCE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3530
Mailing Address - Country:US
Mailing Address - Phone:678-364-8414
Mailing Address - Fax:678-545-0146
Practice Address - Street 1:1000 COMMERCE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3530
Practice Address - Country:US
Practice Address - Phone:678-364-8414
Practice Address - Fax:678-545-0146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA0450232083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
202I933600Medicare PIN