Provider Demographics
NPI:1891667861
Name:AGE-UNDEFINED, PLLC
Entity type:Organization
Organization Name:AGE-UNDEFINED, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:FESTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMSC
Authorized Official - Phone:910-286-6335
Mailing Address - Street 1:2501 LOCKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5026
Mailing Address - Country:US
Mailing Address - Phone:910-286-6335
Mailing Address - Fax:910-786-1602
Practice Address - Street 1:2625 RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5471
Practice Address - Country:US
Practice Address - Phone:910-286-6335
Practice Address - Fax:910-786-1602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-19
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty