Trident Anti Aging, LLC

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

TRIDENT ANTI AGING, LLC

Practice address

800 E Broward Blvd Ste 400
Fort Lauderdale, FL 33301-2033

Phone

(954) 451-5454

NPI assigned

Feb 19, 2019

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

John Poulos

Title

Owner

Phone

(954) 451-5454

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Trident Primary & Preventative Care Doing business as

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Kathryn Hardin Edwards, PA-C

  • Physician Assistant
  • Waldorf, MD
  • NPI 1750716387
  NPD
• Rochelle Christine Dela Paz, D.C., APRN

  • Nurse Practitioner
  • Fort Lauderdale, FL
  • NPI 1295062677
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1550534400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1566777600000",
    "number": "1023574696",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "800 E BROWARD BLVD STE 400",
            "city": "FORT LAUDERDALE",
            "state": "FL",
            "postal_code": "333012033",
            "telephone_number": "954-451-5454"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "800 E BROWARD BLVD STE 400",
            "city": "FORT LAUDERDALE",
            "state": "FL",
            "postal_code": "333012033",
            "telephone_number": "954-451-5454"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRIDENT ANTI AGING, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-02-19",
        "last_updated": "2019-08-26",
        "status": "A",
        "authorized_official_last_name": "POULOS",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "954-451-5454"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1750407086",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1750716387",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Trident Primary & Preventative Care",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Trident Primary & Preventative Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Family Medicine Physician in Fort Lauderdale, FL
• Providers in Fort Lauderdale, FL by specialty
• Family Medicine Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 26, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.