Provider Demographics
NPI:1235454000
Name:THE LOHAD CENTER FOR ANTI-AGING
Entity Type:Organization
Organization Name:THE LOHAD CENTER FOR ANTI-AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KINCART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-645-8778
Mailing Address - Street 1:8761 PERIMETER PARK BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6397
Mailing Address - Country:US
Mailing Address - Phone:904-645-8778
Mailing Address - Fax:
Practice Address - Street 1:8761 PERIMETER PARK BLVD STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6397
Practice Address - Country:US
Practice Address - Phone:904-645-8778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
132700000X
FL0057407207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Multi-Specialty