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General NPI Number Information
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NPI Number | 1184565665
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Entity Type | Organization
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Legal Business Name | VIVIDLY PROFOUND LLC
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Dates
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Enumeration Date | 04/01/2026
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Last Update Date | 04/01/2026
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Provider Practice Location Address
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Address Line | 8210 MACEDONIA COMMONS BLVD STE 3B #2172
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City | MACEDONIA
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State | OH
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Zip | 44056
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Country | US
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Telephone | 440-561-0986
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Fax |
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Provider Business Mailing Address
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Address Line | 8210 MACEDONIA COMMONS BLVD STE 3B #2172
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City | MACEDONIA
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State | OH
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Zip | 44056
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Country | US
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Telephone | 440-561-0986
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Fax |
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Authorized Official
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Title or Position | MEDICAL ASSISTANT/PHLEBOTOMIST
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Name | DESTINY HARRISTON
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Credential | MA
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Telephone | 440-561-0986
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246RP1900X
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Taxonomy Name | Phlebotomy Technician
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License Number |
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License Number State |
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