Provider Demographics
NPI:1841594892
Name:AGE REVERSAL TECHNOLOGIES
Entity Type:Organization
Organization Name:AGE REVERSAL TECHNOLOGIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:316-640-6253
Mailing Address - Street 1:2600 N WOODLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-2729
Mailing Address - Country:US
Mailing Address - Phone:316-640-6253
Mailing Address - Fax:316-858-2523
Practice Address - Street 1:2600 N WOODLAWN BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-2729
Practice Address - Country:US
Practice Address - Phone:316-640-6253
Practice Address - Fax:316-858-2523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00115207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty