Provider Demographics
NPI:1689039000
Name:SOUTH FLORIDA ANTI-AGING & AESTHETICS, LLC
Entity Type:Organization
Organization Name:SOUTH FLORIDA ANTI-AGING & AESTHETICS, LLC
Other - Org Name:STONE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, ARNP, FNP-BC
Authorized Official - Phone:954-906-0399
Mailing Address - Street 1:2050 PARKSIDE CIR S
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-8569
Mailing Address - Country:US
Mailing Address - Phone:954-906-0399
Mailing Address - Fax:954-906-0399
Practice Address - Street 1:500 SE 17TH ST
Practice Address - Street 2:200
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2547
Practice Address - Country:US
Practice Address - Phone:954-906-0399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9182895261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000670200Medicaid