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General NPI Number Information
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NPI Number | 1962133272
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Entity Type | Organization
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Legal Business Name | VIBRANT DIAGNOSTICS LLC
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Dates
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Enumeration Date | 06/19/2022
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Last Update Date | 06/19/2022
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Provider Practice Location Address
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Address Line | 514 2ND LOOP RD STE D
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City | FLORENCE
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State | SC
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Zip | 29505-2848
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Country | US
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Telephone | 843-373-8284
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Fax |
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Provider Business Mailing Address
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Address Line | 108 TIMBERLAKE DR
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City | FLORENCE
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State | SC
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Zip | 29501-9309
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Country | US
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Telephone | 843-373-8284
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHIANDRA KEYATA DAVIS
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Credential |
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Telephone | 843-373-8284
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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