Provider Demographics
NPI:1790151157
Name:VITAL LIVING THERAPEUTIC MASSAGE, LLC
Entity Type:Organization
Organization Name:VITAL LIVING THERAPEUTIC MASSAGE, LLC
Other - Org Name:VITAL LIVING WELLSPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-436-8807
Mailing Address - Street 1:5111 N BEND DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1753
Mailing Address - Country:US
Mailing Address - Phone:260-436-8807
Mailing Address - Fax:260-436-2767
Practice Address - Street 1:5111 N BEND DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1753
Practice Address - Country:US
Practice Address - Phone:260-436-8807
Practice Address - Fax:260-436-2767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28057959A163WM1400X
INMT20901877225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)Group - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty