Provider Demographics
NPI:1609442284
Name:VITAL WELLNESS CHIROPRACTIC PA
Entity Type:Organization
Organization Name:VITAL WELLNESS CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVENICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-207-0176
Mailing Address - Street 1:931 SW ROMAINE LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3605
Mailing Address - Country:US
Mailing Address - Phone:248-207-0176
Mailing Address - Fax:
Practice Address - Street 1:3543 SW CORPORATE PKWY
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-8151
Practice Address - Country:US
Practice Address - Phone:772-232-4091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1013456359OtherFLORIDA DEPARTMENT OF HEALTH