Provider Demographics
NPI:1134551872
Name:VITAL ENERGY OCCUPATIONAL THERAPY & WELLNESS CENTER
Entity type:Organization
Organization Name:VITAL ENERGY OCCUPATIONAL THERAPY & WELLNESS CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HIMA
Authorized Official - Middle Name:N
Authorized Official - Last Name:DALAL
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:803-359-1551
Mailing Address - Street 1:163 CHARTER OAK RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9246
Mailing Address - Country:US
Mailing Address - Phone:803-359-1551
Mailing Address - Fax:803-359-0362
Practice Address - Street 1:450 KILLIAN RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9751
Practice Address - Country:US
Practice Address - Phone:803-359-1551
Practice Address - Fax:803-359-0362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-05
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2626225X00000X
SC6656225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty