Provider Demographics
NPI:1649008491
Name:AGELESS VITALITY CENTER
Entity type:Organization
Organization Name:AGELESS VITALITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIEFKOHL ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-895-2830
Mailing Address - Street 1:4810 W MCELROY AVE UNIT 6
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-3213
Mailing Address - Country:US
Mailing Address - Phone:813-955-4289
Mailing Address - Fax:
Practice Address - Street 1:4810 W MCELROY AVE UNIT 6
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-3213
Practice Address - Country:US
Practice Address - Phone:813-955-4289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center