Healthcare Provider Details

I. General information

NPI: 1174395677
Provider Name (Legal Business Name): VITAL SPRINGS HEALTH SYSTEMS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2023
Last Update Date: 10/27/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12125 HWY 6 UNITS E
FRESNO TX
77545
US

IV. Provider business mailing address

1218 MAGNOLIA DALE DR
FRESNO TX
77545-9680
US

V. Phone/Fax

Practice location:
  • Phone: 979-201-1381
  • Fax:
Mailing address:
  • Phone: 979-201-1381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MACEO SMEDLEY
Title or Position: PRESIDENT
Credential:
Phone: 979-201-1381