Provider Demographics
NPI:1023523750
Name:AGELESS CENTER LLC
Entity type:Organization
Organization Name:AGELESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WYATT
Authorized Official - Middle Name:
Authorized Official - Last Name:HORSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-528-9119
Mailing Address - Street 1:201 PENNSYLVANIA PKWY STE 201
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-1393
Mailing Address - Country:US
Mailing Address - Phone:317-528-9119
Mailing Address - Fax:
Practice Address - Street 1:201 PENNSYLVANIA PKWY STE 201
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-1393
Practice Address - Country:US
Practice Address - Phone:317-528-9119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076865A207RB0002X, 2083B0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Multi-Specialty
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Multi-Specialty