MEDICARE: VITALITY MOBILE WOUND CARE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	163WW0000X	Wound Care Registered Nurse
2	207Q00000X	Family Medicine Physician
3	363LF0000X	Family Nurse Practitioner
4	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1811876824
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY MOBILE WOUND CARE LLC

Provider Business Mailing Address
First Line	:	6115 NEW COPELAND RD STE 640
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-6368
Country	:	US
Telephone Number	:	903-420-3443
Fax Number	:	903-630-8797

Provider Business Practice Location Address
First Line	:	6115 NEW COPELAND RD STE 640
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-6368
Country	:	US
Telephone Number	:	903-420-3443
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CHRISTOPHER LAMAR ETHRIDGE
Credential	:
Telephone Number	:	903-420-3446

Provider Enumeration Date	:	09/02/2025
Last Update Date	:	01/26/2026

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