Provider Demographics
NPI:1679865851
Name:VITAL ENERGY REHAB NC LLC
Entity Type:Organization
Organization Name:VITAL ENERGY REHAB NC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER
Authorized Official - Prefix:
Authorized Official - First Name:HIMA
Authorized Official - Middle Name:N
Authorized Official - Last Name:DALAL
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:803-359-1551
Mailing Address - Street 1:121 CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-8304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9007 MAGNA LN
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-5216
Practice Address - Country:US
Practice Address - Phone:704-698-2104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty