MEDICARE: VITALITY MEDICAL CENTERS OF FORT MILL INC

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1467991109
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY MEDICAL CENTERS OF FORT MILL INC

Provider Business Mailing Address
First Line	:	PO BOX 1320
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29071-1320
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1670 HIGHWAY 160 W STE 201
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-8064
Country	:	US
Telephone Number	:	803-560-6991
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ELISA DENNAE HANDFORD
Credential	:
Telephone Number	:	803-218-9886

Provider Enumeration Date	:	02/14/2017
Last Update Date	:	10/26/2017

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