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General NPI Number Information
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NPI Number | 1205337656
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Entity Type | Organization
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Legal Business Name | VITALITY ACUPUNCTURE LLC
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Dates
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Enumeration Date | 02/21/2018
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Last Update Date | 02/21/2018
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Provider Practice Location Address
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Address Line | 1500 W BARRETT DR
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City | MERIDIAN
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State | ID
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Zip | 83642-3728
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Country | US
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Telephone | 208-629-4920
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Fax | 888-361-5391
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Provider Business Mailing Address
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Address Line | 1500 W BARRETT DR
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City | MERIDIAN
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State | ID
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Zip | 83642-3728
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Country | US
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Telephone | 208-629-4920
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Fax | 888-361-5391
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Authorized Official
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Title or Position | OWNER
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Name | HEATHER ANN BERGSTROM
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Credential | LAC
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Telephone | 208-629-4920
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | ACU279
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License Number State |
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