Provider Demographics
NPI:1639950249
Name:AGING VITALITY LLC
Entity type:Organization
Organization Name:AGING VITALITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTERGARD
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:720-305-8214
Mailing Address - Street 1:472 MEETING ST STE C-140
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-4899
Mailing Address - Country:US
Mailing Address - Phone:720-305-8214
Mailing Address - Fax:
Practice Address - Street 1:472 MEETING ST STE C-140
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-4899
Practice Address - Country:US
Practice Address - Phone:720-305-8214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy