{"npi":"1770160269","type":"NPI-2","status":"active","name":{"display":"Ageless Living Institute LLC","other":[],"organization_name":"AGELESS LIVING INSTITUTE LLC","authorised_official":"Mark Kledzik"},"specialty":{"primary_taxonomy":"363AM0700X","primary_taxonomy_description":"Medical Physician Assistant","slug":"medical-physician-assistant","schema_org_specialty":null,"all":[{"code":"207R00000X","description":"Internal Medicine","primary":false,"state":null,"license":null},{"code":"207T00000X","description":"Neurological Surgery Physician","primary":false,"state":null,"license":null},{"code":"208100000X","description":"Physical Medicine & Rehabilitation","primary":false,"state":null,"license":null},{"code":"2081P2900X","description":"Pain Medicine (Physical Medicine & Rehabilitation) Physician","primary":false,"state":null,"license":null},{"code":"363A00000X","description":"Physician Assistant","primary":false,"state":null,"license":null},{"code":"363AS0400X","description":"Surgical Physician Assistant","primary":false,"state":null,"license":null},{"code":"363AM0700X","description":"Medical Physician Assistant","primary":true,"state":null,"license":null}]},"addresses":[{"purpose":"LOCATION","street_1":"1670 WILLOW CREEK RD STE A","city":"PRESCOTT","state":"AZ","postal_code":"863011112","country_code":"US","phone":"9282555191","fax":"9283169703"},{"purpose":"MAILING","street_1":"1670 WILLOW CREEK RD STE A","city":"PRESCOTT","state":"AZ","postal_code":"863011112","country_code":"US","phone":"9282555191","fax":"9283169703"}],"license":null,"identifiers":[{"type_code":"05","label":"Medicaid","value":"1437452836","state":"AZ","issuer":null}],"pecos":{"enrolled_at":"2026-05-09T10:41:39.028268+00:00","enrollments":[{"enrlmt_id":"O20221208000501","type_code":"12-70","type_desc":"PART B SUPPLIER - CLINIC/GROUP PRACTICE","state":"AZ","pac_id":"3870962152"}]},"enumeration_date":"2021-03-29","last_updated":"2023-02-02","_meta":{"source":"NPPES","snapshot_date":"2023-02-02","doc_url":"https://findmynpi.com/api"}}