Provider Demographics
NPI:1013286533
Name:THE ANTI-AGING AND WELLNESS CENTER
Entity Type:Organization
Organization Name:THE ANTI-AGING AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:601-421-4808
Mailing Address - Street 1:311 FEATHER GLN
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-8703
Mailing Address - Country:US
Mailing Address - Phone:601-421-4808
Mailing Address - Fax:
Practice Address - Street 1:655 LAKE HARBOUR DR STE 900
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4355
Practice Address - Country:US
Practice Address - Phone:601-707-5171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS960070261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service