Provider Demographics
NPI:1093012346
Name:VITALITY HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:VITALITY HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ADEBUSOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-875-7691
Mailing Address - Street 1:2852 DELK RD SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6371
Mailing Address - Country:US
Mailing Address - Phone:770-875-7691
Mailing Address - Fax:
Practice Address - Street 1:2852 DELK RD SE
Practice Address - Street 2:SUITE 201
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-6371
Practice Address - Country:US
Practice Address - Phone:770-875-7691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO08571111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty