1245672856 NPI number — AGELESS WELLNESS CENTER, INC

Table of content: (NPI 1245672856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245672856 NPI number — AGELESS WELLNESS CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGELESS WELLNESS CENTER, INC
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:
Provider Other Organization Name Type Code:
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:
1245672856
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 639
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THIENSVILLE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53092-0639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-247-9005
Provider Business Mailing Address Fax Number:
414-247-9004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2745 W LAYTON AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53221-2651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-475-5800
Provider Business Practice Location Address Fax Number:
414-475-5400
Provider Enumeration Date:
07/24/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SULIEMAN
Authorized Official First Name:
ABDULLATTIEF
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
414-475-5800

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  51008 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1881864197 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: K100110473 . This is a "MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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