Provider Demographics
NPI:1912587239
Name:ENERGY BASE LLC
Entity Type:Organization
Organization Name:ENERGY BASE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIAA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DAC, LAC
Authorized Official - Phone:301-580-4585
Mailing Address - Street 1:1123 STATE ROUTE 3 N STE 282
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1715
Mailing Address - Country:US
Mailing Address - Phone:301-580-4585
Mailing Address - Fax:
Practice Address - Street 1:1629 CROFTON CTR STE 18
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1318
Practice Address - Country:US
Practice Address - Phone:301-580-4585
Practice Address - Fax:240-366-5954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-12
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD764013700Medicaid