Ageless Living Institute LLC
Organization Active NPI Medical Physician Assistant · Prescott, AZ
NPI 1770160269 · NPPES record last updated Feb 2, 2023
Key facts
- NPI
- 1770160269
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Medical Physician Assistant 363AM0700X
- Legal business name
- AGELESS LIVING INSTITUTE LLC
- Practice address
- 1670 Willow Creek Rd Ste a
Prescott, AZ 86301-1112 - Phone
- (928) 255-5191
- Fax
- (928) 316-9703
- NPI assigned
- Mar 29, 2021
- Organization subpart
- No
Authorized official
- Name
- Mr. Mark Joseph Kledzik
- Title
- Member
- Phone
- (928) 255-5191
Practitioners 1
-
Lesley E Wood, D.O.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AZ
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20221208000501 | AZ | Part B Supplier - Clinic/Group Practice | 3870962152 | Practice locations: Prescott, AZ |
National Provider Directory
Locations
1670 Willow Creek Rd
Prescott, AZ 86301
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician |
207R00000X | |||
| Neurological Surgery Physician |
207T00000X | |||
| Physical Medicine & Rehabilitation Physician |
208100000X | |||
| Pain Medicine (Physical Medicine & Rehabilitation) Physician |
2081P2900X | |||
| Physician Assistant |
363A00000X | |||
| Medical Physician Assistant |
363AM0700X | Yes | ||
| Surgical Physician Assistant |
363AS0400X |
Addresses
Primary practice location
1670 Willow Creek Rd Ste a
Prescott, AZ 86301-1112
Mailing address
1670 Willow Creek Rd Ste a
Prescott, AZ 86301-1112
Phone (928) 255-5191
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1437452836 | Medicaid | AZ |
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | admin@aliprescott.com | Direct |
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- Ayad K Agha
- Jeffrey Alexander Aguiar
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All providers in Prescott, AZ · Medical Physician Assistant in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 2, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.