=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861951329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGH VITALITY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2512 S DYE RD
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48532-4153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-931-7394
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10084 SHADYBROOK LN
-----------------------------------------------------
City | GRAND BLANC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48439-8317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-931-7394
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JAMIE GRACE PHILLIPS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 810-931-7392
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------