Healthcare Provider Details

I. General information

NPI: 1497484778
Provider Name (Legal Business Name): FUNCTIONAL VITALITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 WALL ST SE STE 240
CONYERS GA
30013-6702
US

IV. Provider business mailing address

680 GRANDVIEW RD
MANSFIELD GA
30055-2571
US

V. Phone/Fax

Practice location:
  • Phone: 678-278-8348
  • Fax: 470-276-3158
Mailing address:
  • Phone: 470-266-0623
  • Fax: 470-276-3158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LATESS ECHAVARRIA
Title or Position: OWNER
Credential: OT
Phone: 470-266-0623