Provider Demographics
NPI:1154824209
Name:SOUTHLAKE FOOT & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:SOUTHLAKE FOOT & WELLNESS CENTER LLC
Other - Org Name:VITALITY WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VITALITY
Authorized Official - Middle Name:WELLNESS
Authorized Official - Last Name:CLINIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-527-6077
Mailing Address - Street 1:901 W WALL ST STE 103
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-7419
Mailing Address - Country:US
Mailing Address - Phone:817-527-6077
Mailing Address - Fax:
Practice Address - Street 1:6407 COLLEYVILLE BLVD STE B
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6279
Practice Address - Country:US
Practice Address - Phone:817-527-6077
Practice Address - Fax:817-796-1694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-15
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC00108174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty