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General NPI Number Information
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NPI Number | 1992120737
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Entity Type | Organization
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Legal Business Name | VITL HEARTS HTC
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Dates
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Enumeration Date | 03/04/2014
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Last Update Date | 03/04/2014
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Provider Practice Location Address
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Address Line | 122 S 13TH ST
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City | GRIFFIN
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State | GA
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Zip | 30223-2745
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Country | US
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Telephone | 404-932-1667
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Fax | 470-204-7303
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Provider Business Mailing Address
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Address Line | 122 S 13TH ST
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City | GRIFFIN
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State | GA
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Zip | 30223-2745
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Country | US
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Telephone | 404-932-1667
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Fax | 470-204-7303
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Authorized Official
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Title or Position | ADMINISTOR
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Name | PRISCILLA ROBINSON
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Credential | VICE PRESIDENT
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Telephone | 404-932-1667
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 9363
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License Number State | GA
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