MEDICARE: ADVANCED REGENERATIVE HEALTH LLC

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	363LP2300X	Primary Care Nurse Practitioner
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1780465559
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED REGENERATIVE HEALTH LLC

Provider Business Mailing Address
First Line	:	1870 N CORPORATE LAKES BLVD UNIT 267021
Second Line	:
City	:	WESTON
State	:	FL
Zip	:	33326-8837
Country	:	US
Telephone Number	:	754-268-3108
Fax Number	:

Provider Business Practice Location Address
First Line	:	5100 N FEDERAL HWY STE 100
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-3842
Country	:	US
Telephone Number	:	754-268-3108
Fax Number	:

Authorized Official
Title or Position	:	OWNER, CEO
Name	:	MR. JORDAN AUGUSTIN
Credential	:	APRN, PMHNP-BC
Telephone Number	:	954-461-3172

Provider Enumeration Date	:	10/09/2023
Last Update Date	:	10/09/2023

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