=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417833765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPLETE VITALITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2025
-----------------------------------------------------
Last Update Date | 08/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 CELESTE ROAD
-----------------------------------------------------
City | SARALAND
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-561-6010
-----------------------------------------------------
Fax | 855-975-3042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 819 MIMOSA PARK ROAD STE D
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-561-6010
-----------------------------------------------------
Fax | 855-975-3042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | BRENT A TIDWELL
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 205-752-7503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------