Provider Demographics
NPI:1437453545
Name:VITALITY CHIROPRACTIC AND WELLNESS
Entity Type:Organization
Organization Name:VITALITY CHIROPRACTIC AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LIESVELD
Authorized Official - Suffix:
Authorized Official - Credentials:DC,BSN-RN,BA
Authorized Official - Phone:832-671-8569
Mailing Address - Street 1:1205 MEADOWLARK DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-4653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1205 MEADOWLARK DR
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-4653
Practice Address - Country:US
Practice Address - Phone:832-671-8569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11339273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit