MEDICARE: VITAL YOGA THERAPEUTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XN1300X	Neurorehabilitation Occupational Therapist

General Provider Information

NPI Number	:	1376162289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL YOGA THERAPEUTICS, LLC

Provider Business Mailing Address
First Line	:	1199 SAN JOSE FOREST DR
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32080-5412
Country	:	US
Telephone Number	:	904-874-5152
Fax Number	:

Provider Business Practice Location Address
First Line	:	2225 A1A S STE B1
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32080-7906
Country	:	US
Telephone Number	:	904-874-5152
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. LIANA RASCHKE VALLA
Credential	:	OTR/L, IYTT, OMC
Telephone Number	:	904-874-5152

Provider Enumeration Date	:	04/10/2020
Last Update Date	:	04/10/2020

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