The Center for Functional Aesthetic and Anti Aging Medicine Inc

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

Legal business name

THE CENTER FOR FUNCTIONAL AESTHETIC AND ANTI AGING MEDICINE INC

Practice address

571 Avenue K SE
Winter Haven, FL 33880-4215

Phone

(407) 440-0708

NPI assigned

Nov 29, 2024

Last updated

Nov 29, 2024By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dr. Danice Blaise, MD, MBANPI 1255829966

Title

Chief Executive Officer, Owner

Phone

(954) 681-0068

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Enrolled in FL

Enrollment records 1

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Danice Blaise, MD,MBA

  • General Practice Physician
  • Lake Wales, FL
  • NPI 1255829966
  Medicare reassignment Authorized official

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

{
    "created_epoch": "1732838400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732838400000",
    "number": "1508682089",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "571 AVENUE K SE",
            "city": "WINTER HAVEN",
            "state": "FL",
            "postal_code": "338804215",
            "telephone_number": "407-440-0708"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "571 AVENUE K SE",
            "city": "WINTER HAVEN",
            "state": "FL",
            "postal_code": "338804215",
            "telephone_number": "407-440-0708"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE CENTER FOR FUNCTIONAL AESTHETIC AND ANTI AGING MEDICINE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-11-29",
        "last_updated": "2024-11-29",
        "certification_date": "2024-11-28",
        "status": "A",
        "authorized_official_last_name": "BLAISE",
        "authorized_official_first_name": "DANICE",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER, OWNER",
        "authorized_official_telephone_number": "954-681-0068",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD, MBA"
    },
    "taxonomies": [
        {
            "code": "175F00000X",
            "taxonomy_group": "",
            "desc": "Naturopath",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "2083B0002X",
            "taxonomy_group": "",
            "desc": "Preventive Medicine, Obesity Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Internal Medicine Physician in Winter Haven, FL
• Providers in Winter Haven, FL by specialty
• Internal Medicine Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 29, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.