Healthcare Provider Details

I. General information

NPI: 1225813769
Provider Name (Legal Business Name): VIBRANT MENTAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2023
Last Update Date: 05/26/2024
Certification Date: 05/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4213 THEO ST
BIG SPRING TX
79720-7027
US

IV. Provider business mailing address

4213 THEO ST
BIG SPRING TX
79720-7027
US

V. Phone/Fax

Practice location:
  • Phone: 763-568-6378
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: MISS JACKLINE AUKA
Title or Position: OWNER
Credential: NP
Phone: 763-568-6378