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General NPI Number Information
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NPI Number | 1922451376
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Entity Type | Organization
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Legal Business Name | LIFESTYLE PERFORMANCE MEDICINE
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Dates
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Enumeration Date | 07/21/2016
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Last Update Date | 07/25/2016
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Provider Practice Location Address
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Address Line | 24847 COMMERCIAL AVE
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City | ORANGE BEACH
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State | AL
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Zip | 36561-3845
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Country | US
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Telephone | 251-979-2067
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Fax |
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Provider Business Mailing Address
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Address Line | 6506 N DAVIS HWY
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City | PENSACOLA
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State | FL
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Zip | 32504-6957
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Country | US
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Telephone | 850-889-0711
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Fax |
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Authorized Official
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Title or Position | OFFICE CONTACT
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Name | SUSAN VEGA
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Credential |
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Telephone | 850-889-0711
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD34871
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License Number State | AL
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