MEDICARE: VITAL ENERGY OCC THERAPY & WELLNESS CTR 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	261QX0100X	Occupational Medicine Clinic/Center	2626	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11485055	OTHER	SC	CAZH

General Provider Information

NPI Number	:	1700839610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL ENERGY OCC THERAPY & WELLNESS CTR LLC

Provider Business Mailing Address
First Line	:	121 CLEARVIEW DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212
Country	:	US
Telephone Number	:	803-951-3200
Fax Number	:	803-951-0990

Provider Business Practice Location Address
First Line	:	1812 AUGUSTA HWY
Second Line	:	STE L
City	:	LEXINGTON
State	:	SC
Zip	:	29072
Country	:	US
Telephone Number	:	803-359-1551
Fax Number	:	803-233-9201

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. HIMA N DALAL
Credential	:	OCCUPATIONAL THERAPI
Telephone Number	:	803-951-3200

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	04/20/2008

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