Healthcare Provider Details

I. General information

NPI: 1053876979
Provider Name (Legal Business Name): TOTAL VITALITY MEDICAL OF CENTRAL FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2840 N HIAWASSEE RD
ORLANDO FL
32818-3319
US

IV. Provider business mailing address

PO BOX 7982
SEMINOLE FL
33775-7982
US

V. Phone/Fax

Practice location:
  • Phone: 407-720-9688
  • Fax: 407-720-5790
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER A FRIEND
Title or Position: ADMINISTRATOR
Credential:
Phone: 727-849-1309