MEDICARE: ANTI-AGING MEDICAL CENTER

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	363LF0000X	Family Nurse Practitioner	9267806	FL

General Provider Information

NPI Number	:	1265795207
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTI-AGING MEDICAL CENTER

Provider Business Mailing Address
First Line	:	3545 BOBCAT VILLAGE CENTER RD
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34288-8977
Country	:	US
Telephone Number	:	941-625-0304
Fax Number	:

Provider Business Practice Location Address
First Line	:	3545 BOBCAT VILLAGE CENTER RD
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34288-8977
Country	:	US
Telephone Number	:	941-625-0304
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ARNP
Name	:	CHRISTINA M PARKER
Credential	:	ARNP
Telephone Number	:	316-207-3406

Provider Enumeration Date	:	06/22/2012
Last Update Date	:	06/22/2012

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Directions to “ANTI-AGING MEDICAL CENTER ” Practice Location

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