Provider Demographics
NPI:1376162289
Name:VITAL YOGA THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:VITAL YOGA THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LIANA
Authorized Official - Middle Name:RASCHKE
Authorized Official - Last Name:VALLA
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, IYTT, OMC
Authorized Official - Phone:904-874-5152
Mailing Address - Street 1:1199 SAN JOSE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5412
Mailing Address - Country:US
Mailing Address - Phone:904-874-5152
Mailing Address - Fax:
Practice Address - Street 1:2225 A1A S STE B1
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-7906
Practice Address - Country:US
Practice Address - Phone:904-874-5152
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-10
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitationGroup - Single Specialty