Provider Demographics
NPI:1023574696
Name:TRIDENT ANTI AGING, LLC
Entity Type:Organization
Organization Name:TRIDENT ANTI AGING, LLC
Other - Org Name:TRIDENT PRIMARY & PREVENTATIVE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:POULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-451-5454
Mailing Address - Street 1:800 E BROWARD BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2033
Mailing Address - Country:US
Mailing Address - Phone:954-451-5454
Mailing Address - Fax:
Practice Address - Street 1:800 E BROWARD BLVD STE 400
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2033
Practice Address - Country:US
Practice Address - Phone:954-451-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-19
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1750407086Medicaid
GA1750716387Medicaid