Healthcare Provider Details

I. General information

NPI: 1134551872
Provider Name (Legal Business Name): VITAL ENERGY OCCUPATIONAL THERAPY & WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 KILLIAN RD
COLUMBIA SC
29203-9751
US

IV. Provider business mailing address

163 CHARTER OAK RD
LEXINGTON SC
29072-9246
US

V. Phone/Fax

Practice location:
  • Phone: 803-359-1551
  • Fax: 803-359-0362
Mailing address:
  • Phone: 803-359-1551
  • Fax: 803-359-0362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6656
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2626
License Number StateSC

VIII. Authorized Official

Name: MRS. HIMA N DALAL
Title or Position: OWNER
Credential: OTR/L
Phone: 803-359-1551