Provider Demographics
NPI:1700471158
Name:ALTERNATIVE AGING & MEDISPA
Entity Type:Organization
Organization Name:ALTERNATIVE AGING & MEDISPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PHYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:315-777-2749
Mailing Address - Street 1:1388 COSGROVE ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4544
Mailing Address - Country:US
Mailing Address - Phone:315-777-2749
Mailing Address - Fax:
Practice Address - Street 1:1388 COSGROVE ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4544
Practice Address - Country:US
Practice Address - Phone:315-777-2749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty