Provider Demographics
NPI:1538583208
Name:AGELESS MEN'S HEALTH CA, PC
Entity type:Organization
Organization Name:AGELESS MEN'S HEALTH CA, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-818-0446
Mailing Address - Street 1:11940 FOOTHILL BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-9374
Mailing Address - Country:US
Mailing Address - Phone:901-757-3643
Mailing Address - Fax:901-757-7762
Practice Address - Street 1:11940 FOOTHILL BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-9374
Practice Address - Country:US
Practice Address - Phone:901-757-3643
Practice Address - Fax:901-757-7762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty