Provider Demographics
NPI:1104418292
Name:ALLIANCE REGENERATIVE AND PERFORMANCE MEDICINE, PLLC
Entity type:Organization
Organization Name:ALLIANCE REGENERATIVE AND PERFORMANCE MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-258-7224
Mailing Address - Street 1:111 2ND AVE NE STE 1401
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3480
Mailing Address - Country:US
Mailing Address - Phone:727-258-7224
Mailing Address - Fax:
Practice Address - Street 1:111 2ND AVE NE STE 1401
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3480
Practice Address - Country:US
Practice Address - Phone:727-258-7224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty