Provider Demographics
NPI:1669293502
Name:AGELESS BEAUTY MEDICAL SPA LLC
Entity type:Organization
Organization Name:AGELESS BEAUTY MEDICAL SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:774-264-9600
Mailing Address - Street 1:2 CRANDALL RD STE B
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-2646
Mailing Address - Country:US
Mailing Address - Phone:774-264-9600
Mailing Address - Fax:
Practice Address - Street 1:2 CRANDALL RD STE B
Practice Address - Street 2:
Practice Address - City:TIVERTON
Practice Address - State:RI
Practice Address - Zip Code:02878-2646
Practice Address - Country:US
Practice Address - Phone:774-264-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-23
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Multi-Specialty