Provider Demographics
NPI:1588250948
Name:AGE DEFYING EXPERTS SOUTH FLORIDA LLC
Entity type:Organization
Organization Name:AGE DEFYING EXPERTS SOUTH FLORIDA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHETAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:786-505-4423
Mailing Address - Street 1:5379 LYONS RD
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-2810
Mailing Address - Country:US
Mailing Address - Phone:786-505-4423
Mailing Address - Fax:
Practice Address - Street 1:5379 LYONS RD # 1599
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-2810
Practice Address - Country:US
Practice Address - Phone:786-505-4423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-18
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty