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General NPI Number Information
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NPI Number | 1801603717
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Entity Type | Organization
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Legal Business Name | AGE REJUVENATION MEDICAL, P.A.
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Dates
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Enumeration Date | 12/13/2024
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Last Update Date | 01/20/2025
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Provider Practice Location Address
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Address Line | 125 N ORLANDO AVE STE 115
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City | WINTER PARK
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State | FL
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Zip | 32789-3605
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Country | US
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Telephone | 407-565-5929
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Fax |
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Provider Business Mailing Address
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Address Line | 2409 N FALKENBURG RD
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City | TAMPA
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State | FL
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Zip | 33619-0915
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | COO
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Name | YAZMYNE MIRANDA
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Credential |
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Telephone | 954-682-3015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1201X
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Taxonomy Name | Obesity and Weight Management Nutrition Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207QB0002X
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Taxonomy Name | Obesity Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2083B0002X
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Taxonomy Name | Obesity Medicine (Preventive Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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