Healthcare Provider Details

I. General information

NPI: 1568047876
Provider Name (Legal Business Name): AUGUSTA ANTI-AGING MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 PONDER PLACE DR
EVANS GA
30809-3185
US

IV. Provider business mailing address

610 PONDER PLACE DR
EVANS GA
30809-3185
US

V. Phone/Fax

Practice location:
  • Phone: 706-707-2808
  • Fax:
Mailing address:
  • Phone: 706-707-2808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA S TOJINO
Title or Position: SINGLE MEMBER
Credential: DNP, FNP-C
Phone: 706-707-2808