Organization
AGELESS LIVING INSTITUTE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MARK JOSEPH KLEDZIK (MEMBER)
(928) 255-5191
Entity
Organization
Contact information
Practice address
1670 WILLOW CREEK RD STE A, PRESCOTT, AZ 86301-1112
(928) 255-5191
(928) 316-9703
Mailing address
1670 WILLOW CREEK RD STE A, PRESCOTT, AZ 86301-1112
(928) 255-5191
(928) 316-9703
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
—
—
207T00000X
Neurological Surgery Physician
—
—
208100000X
Physical Medicine & Rehabilitation Physician
—
—
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
—
—
363A00000X
Physician Assistant
—
—
363AM0700X
Medical Physician Assistant
Primary
—
—
363AS0400X
Surgical Physician Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1437452836
—
AZ
Enumeration date
03/29/2021
Last updated
02/02/2023
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