=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770189904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIBRANT HEALTH CHOICE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2020
-----------------------------------------------------
Last Update Date | 01/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1247 CARR AVE
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38104-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-901-3621
-----------------------------------------------------
Fax | 662-673-3910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1247 CARR AVE
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38104-4544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-901-3621
-----------------------------------------------------
Fax | 662-673-3910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/OWNER
-----------------------------------------------------
Name | DR. CANDACE MARIE THOMPSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 901-949-1367
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------