1700839610 NPI number — VITAL ENERGY OCC THERAPY & WELLNESS CTR LLC

Table of content: (NPI 1700839610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700839610 NPI number — VITAL ENERGY OCC THERAPY & WELLNESS CTR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITAL ENERGY OCC THERAPY & WELLNESS CTR 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:
1700839610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 CLEARVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-951-3200
Provider Business Mailing Address Fax Number:
803-951-0990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1812 AUGUSTA HWY
Provider Second Line Business Practice Location Address:
STE L
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-359-1551
Provider Business Practice Location Address Fax Number:
803-233-9201
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DALAL
Authorized Official First Name:
HIMA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-951-3200

Provider Taxonomy Codes

  • Taxonomy code: 261QX0100X , with the licence number:  2626 , 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: 11485055 . This is a "CAZH" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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