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General NPI Number Information
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NPI Number | 1730880212
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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 | 03/13/2023
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Last Update Date | 03/13/2023
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Provider Practice Location Address
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Address Line | 2618 E HIGHWAY 37 STE 100
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City | TUTTLE
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State | OK
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Zip | 73089-8479
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Country | US
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Telephone | 405-376-1381
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Fax | 800-488-3294
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Provider Business Mailing Address
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Address Line | 2618 E HIGHWAY 37 STE 100
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City | TUTTLE
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State | OK
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Zip | 73089-8479
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Country | US
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Telephone | 405-376-1381
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Fax | 800-488-3294
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Authorized Official
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Title or Position | OWNER
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Name | DR. LYDIA JEMISON 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 | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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