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General NPI Number Information
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NPI Number | 1295365302
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Entity Type | Organization
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Legal Business Name | VIBRANT LIFE DIRECT CARE, PLLC
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Dates
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Enumeration Date | 01/17/2020
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Last Update Date | 01/17/2020
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Provider Practice Location Address
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Address Line | 501 N MUSTANG RD STE B
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City | MUSTANG
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State | OK
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Zip | 73064-7044
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Country | US
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Telephone | 405-708-3385
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Fax | 800-488-3294
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Provider Business Mailing Address
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Address Line | 5225 E TYLER DR
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City | TUTTLE
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State | OK
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Zip | 73089-8305
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Country | US
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Telephone | 405-708-3385
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LYDIA J. DENNIS
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Credential | DO
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Telephone | 405-708-3385
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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