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Organization
TRIDENT ANTI AGING, LLC
Active
Organization
TRIDENT ANTI AGING, LLC
Active
Other names
Trident Primary & Preventative Care
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN POULOS (OWNER)
(954) 451-5454
Entity
Organization
Contact information
Practice address
800 E BROWARD BLVD STE 400, FORT LAUDERDALE, FL 33301-2033
(954) 451-5454
Mailing address
800 E BROWARD BLVD STE 400, FORT LAUDERDALE, FL 33301-2033
(954) 451-5454
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1750407086
—
FL
05
—
1750716387
—
GA
Enumeration date
02/19/2019
Last updated
08/26/2019
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