Basic Information
| Provider Information | |||||||||
| NPI: | 1134551872 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VITAL ENERGY OCCUPATIONAL THERAPY & WELLNESS CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VITAL ENERGY THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 163 CHARTER OAK RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290729246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033591551 | ||||||||
| FaxNumber: | 8033590362 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 KILLIAN RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292039751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033591551 | ||||||||
| FaxNumber: | 8033590362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2013 | ||||||||
| LastUpdateDate: | 08/06/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DALAL | ||||||||
| AuthorizedOfficialFirstName: | HIMA | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8033591551 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | OTR/L | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 2626 | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | 6656 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.