Organization
AGELESS ATHLETES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DENISE BRADFORD-HENRY DPM (DIRECTOR)
(248) 565-4024
Entity
Organization
Contact information
Practice address
2000 TOWN CTR STE 1900, SOUTHFIELD, MI 48075-1152
(248) 565-4024
(775) 587-3115
Mailing address
PO BOX 781, SOUTHFIELD, MI 48037-0781
(248) 565-4024
(775) 587-3115
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
001148
MI
213EP1101X
Primary Podiatric Medicine Podiatrist
001148
MI
213ES0000X
Sports Medicine Podiatrist
001148
MI
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
335E00000X
Prosthetic/Orthotic Supplier
—
—
Other
Enumeration date
03/22/2007
Last updated
02/15/2008
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