Provider Demographics
NPI:1760528806
Name:ANTI AGING CONCEPTS, LLC
Entity Type:Organization
Organization Name:ANTI AGING CONCEPTS, LLC
Other - Org Name:PROFESSIONAL PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RAYFORD
Authorized Official - Last Name:KEEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:423-892-8635
Mailing Address - Street 1:1510 GUNBARREL RD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7174
Mailing Address - Country:US
Mailing Address - Phone:423-892-8635
Mailing Address - Fax:423-892-8106
Practice Address - Street 1:1510 GUNBARREL RD
Practice Address - Street 2:SUITE 700
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-7174
Practice Address - Country:US
Practice Address - Phone:423-892-8635
Practice Address - Fax:423-892-8106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4141332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5427400001Medicare NSC