MEDICARE: VITALITY AESTHETICS AND WELLNESS, 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	261QP2300X	Primary Care Clinic/Center	2313-9790	WV

General Provider Information

NPI Number	:	1841725454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY AESTHETICS AND WELLNESS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 329
Second Line	:
City	:	FAYETTEVILLE
State	:	WV
Zip	:	25840-0329
Country	:	US
Telephone Number	:	304-574-9876
Fax Number	:	304-900-5522

Provider Business Practice Location Address
First Line	:	211 W MAPLE AVE
Second Line	:
City	:	FAYETTEVILLE
State	:	WV
Zip	:	25840-1445
Country	:	US
Telephone Number	:	304-574-9876
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	MARY E LAGOS
Credential	:
Telephone Number	:	304-574-9876

Provider Enumeration Date	:	04/21/2017
Last Update Date	:	04/21/2017

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