Organization
LIFESTYLE PERFORMANCE MEDICINE
Active
Other names
Regenesis LLC
Organization subpart
No
Provider details
NPI number
Authorized official
SUSAN VEGA (OFFICE CONTACT)
(850) 889-0711
Entity
Organization
Contact information
Practice address
24847 COMMERCIAL AVE, ORANGE BEACH, AL 36561-3845
(251) 979-2067
Mailing address
6506 N DAVIS HWY, PENSACOLA, FL 32504-6957
(850) 889-0711
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MD34871
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
MD34871
MEDICAL LICENSE-ALABAMA
AL
01
—
ME83357
MEDICAL LICENSE-FLORIDA
FL
01
—
PA1108
MEDICAL LICENSE-ALABAMA
AL
01
—
PA9108469
MEDICAL LICENSE-FLORIDA
FL
Enumeration date
07/21/2016
Last updated
07/25/2016
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