Provider Demographics
NPI:1689012627
Name:CENTER FOR ANTI-AGING
Entity Type:Organization
Organization Name:CENTER FOR ANTI-AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALLENDE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:925-838-9996
Mailing Address - Street 1:588 SAN RAMON VALLEY BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-4086
Mailing Address - Country:US
Mailing Address - Phone:925-838-9996
Mailing Address - Fax:530-676-5487
Practice Address - Street 1:588 SAN RAMON VALLEY BLVD
Practice Address - Street 2:STE 100
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4086
Practice Address - Country:US
Practice Address - Phone:925-838-9996
Practice Address - Fax:530-676-5487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA781895163W00000X
CAG28372174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty