MEDICARE: TRIDENT ANTI AGING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023574696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIDENT ANTI AGING, LLC

Provider Business Mailing Address
First Line	:	800 E BROWARD BLVD STE 400
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2033
Country	:	US
Telephone Number	:	954-451-5454
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 E BROWARD BLVD STE 400
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2033
Country	:	US
Telephone Number	:	954-451-5454
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN POULOS
Credential	:
Telephone Number	:	954-451-5454

Provider Enumeration Date	:	02/19/2019
Last Update Date	:	08/26/2019

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