Provider Demographics
NPI:1063089266
Name:VITALITY HEALTHCARE SERVICES LLC
Entity type:Organization
Organization Name:VITALITY HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:TYRONE
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:APRN
Authorized Official - Phone:864-384-5277
Mailing Address - Street 1:400 PLAZA CIR STE G
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-7558
Mailing Address - Country:US
Mailing Address - Phone:864-403-9150
Mailing Address - Fax:
Practice Address - Street 1:400 PLAZA CIR STE G
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7558
Practice Address - Country:US
Practice Address - Phone:864-403-9150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-07
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care