Healthcare Provider Details

I. General information

NPI: 1053716860
Provider Name (Legal Business Name): VITALITY A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 BROADWATER AVE
BILLINGS MT
59102-4867
US

IV. Provider business mailing address

1918 BROADWATER AVE
BILLINGS MT
59102-4867
US

V. Phone/Fax

Practice location:
  • Phone: 406-969-3805
  • Fax: 406-794-0809
Mailing address:
  • Phone: 406-969-3805
  • Fax: 406-794-0809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1017
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number1017
License Number StateMT

VIII. Authorized Official

Name: DR. JEFFREY R MITCHELL
Title or Position: ONWER
Credential: D.C.
Phone: 406-969-3805