=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538860689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUR VITALITY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2023
-----------------------------------------------------
Last Update Date | 03/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2717 N 4TH ST STE 120
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86004-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-440-8494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2532 N 4TH ST # 278
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86004-3712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-999-9974
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TERESE MARIE SCHMIDT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-440-8494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------