MEDICARE: NEURO VITALITY PHYSICAL THERAPY AND WELLNESS INC

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1679393813
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEURO VITALITY PHYSICAL THERAPY AND WELLNESS INC

Provider Business Mailing Address
First Line	:	4774 GROVE FIELD PARK
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024-6780
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4774 GROVE FIELD PARK
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024-6780
Country	:	US
Telephone Number	:	404-909-2948
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JANET HAGYE
Credential	:	PT
Telephone Number	:	404-909-2948

Provider Enumeration Date	:	10/14/2024
Last Update Date	:	10/14/2024

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