Healthcare Provider Details

I. General information

NPI: 1235777442
Provider Name (Legal Business Name): VITALITY AT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 LUCE ST SW
GRAND RAPIDS MI
49534-9607
US

IV. Provider business mailing address

247 LUCE ST SW
GRAND RAPIDS MI
49534-9607
US

V. Phone/Fax

Practice location:
  • Phone: 612-839-9040
  • Fax:
Mailing address:
  • Phone: 612-839-9040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JENNAFER SMITH
Title or Position: PHYSICAL THERAPIST
Credential: DPT, GCS
Phone: 612-839-9040