Healthcare Provider Details

I. General information

NPI: 1336879741
Provider Name (Legal Business Name): FUNCTIONAL VITALITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

680 GRANDVIEW RD
MANSFIELD GA
30055-2571
US

IV. Provider business mailing address

680 GRANDVIEW RD
MANSFIELD GA
30055-2571
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

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