1760528806 NPI number — ANTI AGING CONCEPTS, LLC

Table of content: (NPI 1760528806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760528806 NPI number — ANTI AGING CONCEPTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTI AGING CONCEPTS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROFESSIONAL PHARMACY SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760528806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1510 GUNBARREL RD
Provider Second Line Business Mailing Address:
SUITE 700
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37421-7174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-892-8635
Provider Business Mailing Address Fax Number:
423-892-8106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 GUNBARREL RD
Provider Second Line Business Practice Location Address:
SUITE 700
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37421-7174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-892-8635
Provider Business Practice Location Address Fax Number:
423-892-8106
Provider Enumeration Date:
01/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KEEL
Authorized Official First Name:
GARY
Authorized Official Middle Name:
RAYFORD
Authorized Official Title or Position:
CHIEF MANAGER
Authorized Official Telephone Number:
423-892-8635

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  4141 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 4141 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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