Provider Demographics
NPI:1689321382
Name:DESTINATION VITALITY LTD
Entity Type:Organization
Organization Name:DESTINATION VITALITY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLIK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:570-637-1028
Mailing Address - Street 1:20 MY WAY LN
Mailing Address - Street 2:
Mailing Address - City:BEACH LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:18405-3111
Mailing Address - Country:US
Mailing Address - Phone:570-637-1028
Mailing Address - Fax:877-675-2576
Practice Address - Street 1:1041 BEACH LAKE HWY STE 2
Practice Address - Street 2:
Practice Address - City:BEACH LAKE
Practice Address - State:PA
Practice Address - Zip Code:18405-3009
Practice Address - Country:US
Practice Address - Phone:570-801-9488
Practice Address - Fax:877-675-2576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-03
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service