Provider Demographics
NPI:1689395782
Name:AGELESS RESTORATION LLC
Entity Type:Organization
Organization Name:AGELESS RESTORATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:405-928-4229
Mailing Address - Street 1:PO BOX 15782
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73155-5782
Mailing Address - Country:US
Mailing Address - Phone:405-455-3964
Mailing Address - Fax:210-800-9921
Practice Address - Street 1:3351 W ROCK CREEK RD STE 100
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-2463
Practice Address - Country:US
Practice Address - Phone:405-928-4229
Practice Address - Fax:405-561-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care