Provider Demographics
NPI:1134468127
Name:VITAL ENERGY OCCUPATIONAL THERAPY & WELLNESS CTR
Entity type:Organization
Organization Name:VITAL ENERGY OCCUPATIONAL THERAPY & WELLNESS CTR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:SUZY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAY
Authorized Official - Suffix:
Authorized Official - Credentials:
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 1:4114 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4316
Practice Address - Country:US
Practice Address - Phone:803-359-1551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VITAL ENERGY OCCUPATIONAL THERAPY AND WELLNESS CTR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9433OtherMEDICARE PTAN