Healthcare Provider Details

I. General information

NPI: 1104418292
Provider Name (Legal Business Name): ALLIANCE REGENERATIVE AND PERFORMANCE MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 2ND AVE NE STE 1401
ST PETERSBURG FL
33701-3480
US

IV. Provider business mailing address

111 2ND AVE NE STE 1401
ST PETERSBURG FL
33701-3480
US

V. Phone/Fax

Practice location:
  • Phone: 727-258-7224
  • Fax:
Mailing address:
  • Phone: 727-258-7224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN BROUSSARD
Title or Position: OWNER
Credential: DO
Phone: 727-258-7224