Healthcare Provider Details

I. General information

NPI: 1033881321
Provider Name (Legal Business Name): VITALITY HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 NORTH AVE NW STE C
ATLANTA GA
30318-6909
US

IV. Provider business mailing address

33 BLUE RIDGE TRL
POWDER SPRINGS GA
30127-6877
US

V. Phone/Fax

Practice location:
  • Phone: 404-477-2300
  • Fax: 404-477-2301
Mailing address:
  • Phone: 678-467-0587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. CLAYTON GIBSON III
Title or Position: CEO
Credential: DC, PH.D.
Phone: 404-477-2300