Healthcare Provider Details

I. General information

NPI: 1912587239
Provider Name (Legal Business Name): ENERGY BASE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1629 CROFTON CTR STE 18
CROFTON MD
21114-1318
US

IV. Provider business mailing address

1123 STATE ROUTE 3 N STE 282
GAMBRILLS MD
21054-1715
US

V. Phone/Fax

Practice location:
  • Phone: 301-580-4585
  • Fax: 240-366-5954
Mailing address:
  • Phone: 301-580-4585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: DR. TIAA C. HARTLEY
Title or Position: OWNER
Credential: D.AC, L.AC
Phone: 301-580-4585