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General NPI Number Information
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NPI Number | 1154750321
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Entity Type | Organization
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Legal Business Name | VITALITY GROUP OF WNY
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Dates
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Enumeration Date | 11/07/2013
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Last Update Date | 11/07/2013
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Provider Practice Location Address
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Address Line | 3670 MCKINLEY PKWY MASSAGE ENVY
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City | BLASDELL
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State | NY
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Zip | 14219-2696
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Country | US
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Telephone | 716-822-3689
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Fax |
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Provider Business Mailing Address
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Address Line | 2338 IMMOKALEE RD #105
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City | NAPLES
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State | FL
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Zip | 34110-1445
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Country | US
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Telephone | 239-269-3279
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. FRED GRANT MORSE III
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Credential |
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Telephone | 239-269-3279
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 21MA1407640
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License Number State | NY
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