Healthcare Provider Details

I. General information

NPI: 1376162289
Provider Name (Legal Business Name): VITAL YOGA THERAPEUTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 04/10/2020
Certification Date: 04/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 A1A S STE B1
SAINT AUGUSTINE FL
32080-7906
US

IV. Provider business mailing address

1199 SAN JOSE FOREST DR
SAINT AUGUSTINE FL
32080-5412
US

V. Phone/Fax

Practice location:
  • Phone: 904-874-5152
  • Fax:
Mailing address:
  • Phone: 904-874-5152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. LIANA RASCHKE VALLA
Title or Position: OWNER
Credential: OTR/L, IYTT, OMC
Phone: 904-874-5152