Provider Demographics
NPI:1710692470
Name:AGELESS FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:AGELESS FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAPONNO
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:405-512-4881
Mailing Address - Street 1:1833 OLDE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-3244
Mailing Address - Country:US
Mailing Address - Phone:405-512-4881
Mailing Address - Fax:
Practice Address - Street 1:5300 N MERIDIAN AVE STE 8
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2137
Practice Address - Country:US
Practice Address - Phone:405-768-2121
Practice Address - Fax:405-768-2232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty