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General NPI Number Information
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NPI Number | 1841725454
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Entity Type | Organization
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Legal Business Name | VITALITY AESTHETICS AND WELLNESS, LLC
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Dates
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Enumeration Date | 04/21/2017
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Last Update Date | 04/21/2017
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Provider Practice Location Address
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Address Line | 211 W MAPLE AVE
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City | FAYETTEVILLE
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State | WV
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Zip | 25840-1445
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Country | US
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Telephone | 304-574-9876
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 329
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City | FAYETTEVILLE
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State | WV
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Zip | 25840-0329
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Country | US
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Telephone | 304-574-9876
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Fax | 304-900-5522
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Authorized Official
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Title or Position | OPERATIONS MANAGER
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Name | MARY E LAGOS
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Credential |
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Telephone | 304-574-9876
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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 | 2313-9790
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License Number State | WV
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