1194986596 NPI number — VITAL CARE ONE, LLC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194986596 NPI number — VITAL CARE ONE, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITAL CARE ONE, LLC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194986596
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 MEROVAN DR STE 1
Provider Second Line Business Mailing Address:
P.O. BOX 6099
Provider Business Mailing Address City Name:
NORTH AUGUSTA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29860-8645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-426-8052
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 MEROVAN DR STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH AUGUSTA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29860-8645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-426-8052
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
803-295-6190

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 007400300A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: AB0273 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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