Provider Demographics
NPI:1811792864
Name:WLC VITALITY IN MOTION THERAPY TEAM
Entity type:Organization
Organization Name:WLC VITALITY IN MOTION THERAPY TEAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:618-713-5284
Mailing Address - Street 1:35 S VINE ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-1738
Mailing Address - Country:US
Mailing Address - Phone:618-713-5284
Mailing Address - Fax:618-294-8699
Practice Address - Street 1:35 S VINE ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-1738
Practice Address - Country:US
Practice Address - Phone:618-713-5284
Practice Address - Fax:618-294-8699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-14
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation