Healthcare Provider Details

I. General information

NPI: 1245772672
Provider Name (Legal Business Name): VITAL PERSONALIZED HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 PLANTATION PARK DR BLDG 400
BLUFFTON SC
29910
US

IV. Provider business mailing address

23 PLANTATION PARK DR STE B
BLUFFTON SC
29910-6038
US

V. Phone/Fax

Practice location:
  • Phone: 803-460-5699
  • Fax:
Mailing address:
  • Phone: 803-460-5699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMDO 985 DO
License Number StateSC

VIII. Authorized Official

Name: CHRISTOPHER W. LEBLANC
Title or Position: OWNER/PHYSICIAN
Credential: DO
Phone: 843-815-5566