Provider Demographics
NPI:1093226995
Name:ADVANCED ANTI AGING LLC
Entity Type:Organization
Organization Name:ADVANCED ANTI AGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LIZARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-244-1396
Mailing Address - Street 1:3307 ISLA VERDE AVE., SURFSIDE MANSIONS
Mailing Address - Street 2:APT 1105
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979
Mailing Address - Country:US
Mailing Address - Phone:315-244-1396
Mailing Address - Fax:
Practice Address - Street 1:29 WASHINGTON STREET ASHFORD MEDICAL CENTER
Practice Address - Street 2:SUITE 310
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907
Practice Address - Country:US
Practice Address - Phone:787-400-9779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty