MEDICARE: VITAL ENERGY

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	261Q00000X	Clinic/Center	2626	SC

General Provider Information

NPI Number	:	1962697771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL ENERGY

Provider Business Mailing Address
First Line	:	121 CLEARVIEW DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-8304
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1812 AUGUSTA HWY STE L
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29072-1915
Country	:	US
Telephone Number	:	803-233-3049
Fax Number	:	203-233-9201

Authorized Official
Title or Position	:	OWNER
Name	:	HIMA N DALAL
Credential	:	OT
Telephone Number	:	803-233-3049

Provider Enumeration Date	:	09/14/2007
Last Update Date	:	09/14/2007

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Directions to “VITAL ENERGY ” Practice Location

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