Provider Demographics
NPI:1245772672
Name:VITAL PERSONALIZED HEALTHCARE, LLC
Entity Type:Organization
Organization Name:VITAL PERSONALIZED HEALTHCARE, LLC
Other - Org Name:COASTAL CONCIERGE CARE, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEBLANC
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:843-815-5566
Mailing Address - Street 1:23 PLANTATION PARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-6038
Mailing Address - Country:US
Mailing Address - Phone:803-460-5699
Mailing Address - Fax:
Practice Address - Street 1:23 PLANTATION PARK DR
Practice Address - Street 2:BLDG 400
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910
Practice Address - Country:US
Practice Address - Phone:803-460-5699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMDO 985 DO207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA1405E499Medicare UPIN