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General NPI Number Information
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NPI Number | 1700779659
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Entity Type | Organization
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Legal Business Name | ELITE PERFORMANCE AND LONGEVITY CENTER, CORP.
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Dates
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Enumeration Date | 05/30/2025
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Last Update Date | 05/30/2025
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Provider Practice Location Address
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Address Line | 2030 BEE RIDGE RD STE B
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City | SARASOTA
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State | FL
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Zip | 34239-6108
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Country | US
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Telephone | 941-809-5794
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Fax |
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Provider Business Mailing Address
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Address Line | 2030 BEE RIDGE RD STE B
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City | SARASOTA
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State | FL
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Zip | 34239-6108
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Country | US
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Telephone | 941-809-5794
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. CARLOS DIAZ
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Credential | MD
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Telephone | 941-809-5794
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 202D00000X
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Taxonomy Name | Integrative Medicine Physician
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License Number |
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License Number State |
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