=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467013565
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIBRANT HEALTH, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2019
-----------------------------------------------------
Last Update Date | 06/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3425 E LOCUST ST STE 101
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52803-3573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-271-2428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3425 E LOCUST ST STE 101
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52803-3573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-271-2428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LINDA JAGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 563-271-2428
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------