Provider Demographics
NPI:1215048145
Name:VIBRANCE MEDICAL SPA & WELLNESS CENTER, PLLC
Entity type:Organization
Organization Name:VIBRANCE MEDICAL SPA & WELLNESS CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MYRIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-830-9001
Mailing Address - Street 1:1025 WH SMITH BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5278
Mailing Address - Country:US
Mailing Address - Phone:252-830-9001
Mailing Address - Fax:252-830-9002
Practice Address - Street 1:1006B WH SMITH BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5051
Practice Address - Country:US
Practice Address - Phone:252-830-9001
Practice Address - Fax:252-830-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401167207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8927025Medicaid
NC8927025Medicaid
NCF92914Medicare UPIN