Provider Demographics
NPI:1891944211
Name:ENERGETIC EXPRESSIONS
Entity Type:Organization
Organization Name:ENERGETIC EXPRESSIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ALYSON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DIEHL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:407-257-7239
Mailing Address - Street 1:407 LAKE HOWELL RD
Mailing Address - Street 2:SUITE #110
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5908
Mailing Address - Country:US
Mailing Address - Phone:407-257-7239
Mailing Address - Fax:
Practice Address - Street 1:407 LAKE HOWELL RD
Practice Address - Street 2:SUITE #110
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5908
Practice Address - Country:US
Practice Address - Phone:407-257-7239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM21115261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center