Healthcare Provider Details

I. General information

NPI: 1740678937
Provider Name (Legal Business Name): THE VITAL POTENTIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 S YUKON ST SUITE 320,
LAKEWOOD CO
80226-4354
US

IV. Provider business mailing address

12081 W ALAMEDA PKWY SUITE 480
LAKEWOOD CO
80228-2701
US

V. Phone/Fax

Practice location:
  • Phone: 303-642-0376
  • Fax:
Mailing address:
  • Phone: 720-316-0196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberMT.00165404
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberMT-0016504
License Number StateCO

VIII. Authorized Official

Name: MRS. JAMIE LYNN THOMAS
Title or Position: OWNER & PRACTITIONER
Credential: NMT, RMT, LDMT, CST,
Phone: 303-642-0376