Provider Demographics
NPI:1497484778
Name:FUNCTIONAL VITALITY
Entity Type:Organization
Organization Name:FUNCTIONAL VITALITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATESS
Authorized Official - Middle Name:
Authorized Official - Last Name:ECHAVARRIA
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:470-266-0623
Mailing Address - Street 1:680 GRANDVIEW RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:GA
Mailing Address - Zip Code:30055-2571
Mailing Address - Country:US
Mailing Address - Phone:470-266-0623
Mailing Address - Fax:470-276-3158
Practice Address - Street 1:2375 WALL ST SE STE 240
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6702
Practice Address - Country:US
Practice Address - Phone:678-278-8348
Practice Address - Fax:470-276-3158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-10
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty