MEDICARE: TOTAL VITALITY HEALTH CARE 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	111N00000X	Chiropractor	CH5548	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BA793	OTHER	FL	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CH5548	OTHER	FL	STATE LICENSE

General Provider Information

NPI Number	:	1821252982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOTAL VITALITY HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	2717 SANTA BARBARA BLVD
Second Line	:	# 8
City	:	CAPE CORAL
State	:	FL
Zip	:	33914-4432
Country	:	US
Telephone Number	:	239-458-5747
Fax Number	:	239-772-8747

Provider Business Practice Location Address
First Line	:	2717 SANTA BARBARA BLVD
Second Line	:	#8
City	:	CAPE CORAL
State	:	FL
Zip	:	33914-4432
Country	:	US
Telephone Number	:	239-458-5747
Fax Number	:	239-772-8747

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. KRISTINE KAY JOHNSON
Credential	:	DC
Telephone Number	:	239-458-5747

Provider Enumeration Date	:	07/17/2008
Last Update Date	:	09/30/2011

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Directions to “TOTAL VITALITY HEALTH CARE LLC ” Practice Location

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