Basic Information
| Provider Information | |||||||||
| NPI: | 1558937730 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AGELESS MEDICA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11841 MASON MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452491748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375444020 | ||||||||
| FaxNumber: | 9375444009 | ||||||||
| Practice Location | |||||||||
| Address1: | 11841 MASON MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452491748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375444020 | ||||||||
| FaxNumber: | 9375444009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2021 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | RAO | ||||||||
| AuthorizedOfficialFirstName: | SHRI | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9375444020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
No ID Information.