1164742870 NPI number — VITALITY HEALTH AND WELLNESS PLLC

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 1164742870 NPI number — VITALITY HEALTH AND WELLNESS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITALITY HEALTH AND WELLNESS PLLC
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:
1164742870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1429 E FIRETOWER RD
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27858-5731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-364-2802
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1429 E FIRE TOWER RD
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27858-5730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-364-2802
Provider Business Practice Location Address Fax Number:
252-207-0709
Provider Enumeration Date:
06/03/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SPEECE
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
I
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
252-364-2802

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  5004454 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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