1245772672 NPI number — VITAL PERSONALIZED HEALTHCARE, LLC

Table of content: (NPI 1245772672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245772672 NPI number — VITAL PERSONALIZED HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITAL PERSONALIZED HEALTHCARE, 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:
6
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:
1245772672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 PLANTATION PARK DR STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLUFFTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29910-6038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-460-5699
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 PLANTATION PARK DR
Provider Second Line Business Practice Location Address:
BLDG 400
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-460-5699
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LEBLANC
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
843-815-5566

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MDO 985 DO , 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)





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