MEDICARE: DESTINATION VITALITY LTD

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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1689321382
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINATION VITALITY LTD

Provider Business Mailing Address
First Line	:	20 MY WAY LN
Second Line	:
City	:	BEACH LAKE
State	:	PA
Zip	:	18405-3111
Country	:	US
Telephone Number	:	570-637-1028
Fax Number	:	877-675-2576

Provider Business Practice Location Address
First Line	:	310 SUNRISE AVE STE B
Second Line	:
City	:	HONESDALE
State	:	PA
Zip	:	18431-1032
Country	:	US
Telephone Number	:	570-801-9488
Fax Number	:	877-675-2576

Authorized Official
Title or Position	:	OWNER
Name	:	DANA GALLIK
Credential	:	CRNP
Telephone Number	:	570-637-1028

Provider Enumeration Date	:	03/03/2022
Last Update Date	:	10/31/2024

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Directions to “DESTINATION VITALITY LTD ” Practice Location

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