Healthcare Provider Details

I. General information

NPI: 1326886854
Provider Name (Legal Business Name): VETERAN LIFE VITALITY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 RICE ST
MEADVILLE MO
64659-9210
US

IV. Provider business mailing address

206 RICE ST
MEADVILLE MO
64659-9210
US

V. Phone/Fax

Practice location:
  • Phone: 660-973-6617
  • Fax:
Mailing address:
  • Phone: 660-973-6617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: DR. PARRY WAYNE CLARK
Title or Position: CEO AND MANAGING MEMBER
Credential: JD, PHD, MSM
Phone: 660-973-6617