Provider Demographics
NPI:1922451376
Name:LIFESTYLE PERFORMANCE MEDICINE
Entity Type:Organization
Organization Name:LIFESTYLE PERFORMANCE MEDICINE
Other - Org Name:REGENESIS LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE CONTACT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-889-0711
Mailing Address - Street 1:6506 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-6957
Mailing Address - Country:US
Mailing Address - Phone:850-889-0711
Mailing Address - Fax:
Practice Address - Street 1:24847 COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:ORANGE BEACH
Practice Address - State:AL
Practice Address - Zip Code:36561-3845
Practice Address - Country:US
Practice Address - Phone:251-979-2067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-21
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD34871174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9108469OtherMEDICAL LICENSE-FLORIDA
ALMD34871OtherMEDICAL LICENSE-ALABAMA
ALPA1108OtherMEDICAL LICENSE-ALABAMA
FLME83357OtherMEDICAL LICENSE-FLORIDA