Healthcare Provider Details

I. General information

NPI: 1790151157
Provider Name (Legal Business Name): VITAL LIVING THERAPEUTIC MASSAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 N BEND DR
FORT WAYNE IN
46804-1753
US

IV. Provider business mailing address

5111 N BEND DR
FORT WAYNE IN
46804-1753
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-8807
  • Fax: 260-436-2767
Mailing address:
  • Phone: 260-436-8807
  • Fax: 260-436-2767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT20901877
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number28057959A
License Number StateIN

VIII. Authorized Official

Name: JANET CARROLL
Title or Position: OWNER
Credential:
Phone: 260-436-8807