MEDICARE: VITAL ENERGY OCCUPATIONAL THERAPY & WELLNESS CTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist
2	225X00000X	Occupational Therapist

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9433	OTHER	SC	MEDICARE PTAN

General Provider Information

NPI Number	:	1134468127
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL ENERGY OCCUPATIONAL THERAPY & WELLNESS CTR

Provider Business Mailing Address
First Line	:	121 CLEARVIEW DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-8304
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4114 FOREST DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-4316
Country	:	US
Telephone Number	:	803-359-1551
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MGR
Name	:	SUZY SHAY
Credential	:
Telephone Number	:	803-359-1551

Provider Enumeration Date	:	02/11/2013
Last Update Date	:	02/11/2013

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