Organization Name: | THE ANTI-AGING AND WELLNESS CENTER |
NPI Number: | 1013286533 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | DONALD RAY BONNER (OWNER) |
Mailing Address: | 655 Lake Harbour Dr Ste 900 Ridgeland |
State: | MS US |
Postal Code: | 391574355 |
Phone Number: | 6017075171 |
Fax Number: | |
NPI Enumeration Date: | 12/29/2011 |
NPI Last Update Date: | 12/29/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QH0100X |
License Number: | 960070 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MS |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Health Service |
Taxonomy Definition: |