=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538058755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITALITY IV THERAPY AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2025
-----------------------------------------------------
Last Update Date | 07/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 S RAY ROBERTS PKWY STE B
-----------------------------------------------------
City | TIOGA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76271-3656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-289-4799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 S RAY ROBERTS PKWY STE B
-----------------------------------------------------
City | TIOGA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76271-3656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-289-4799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VELISLAVA MIDDLETON
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 214-499-4107
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------