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General NPI Number Information
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NPI Number | 1285751008
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Entity Type | Organization
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Legal Business Name | VITALITY ANTI-AGING CENTER AND MED SPA
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Dates
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Enumeration Date | 03/25/2007
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Last Update Date | 11/24/2014
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Provider Practice Location Address
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Address Line | 74 8TH ST SE SUITE 101
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City | HICKORY
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State | NC
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Zip | 28602-1130
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Country | US
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Telephone | 828-322-1498
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Fax | 828-322-2835
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Provider Business Mailing Address
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Address Line | 74 8TH STREET SE SUITE 101
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City | HICKORY
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State | NC
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Zip | 28602-4942
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Country | US
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Telephone | 828-322-1498
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Fax | 828-322-2835
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Authorized Official
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Title or Position | OWNER
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Name | GRACE MCLAURIN
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Credential | PA
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Telephone | 828-322-1498
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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