Provider Demographics
NPI:1659610145
Name:AGELESS SECRET
Entity Type:Organization
Organization Name:AGELESS SECRET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:ZAFUTO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:480-948-3250
Mailing Address - Street 1:7425 E SHEA BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6411
Mailing Address - Country:US
Mailing Address - Phone:480-948-3250
Mailing Address - Fax:480-948-3750
Practice Address - Street 1:7425 E SHEA BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6411
Practice Address - Country:US
Practice Address - Phone:480-948-3250
Practice Address - Fax:480-948-3750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4668207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty