Provider Demographics
NPI:1801054416
Name:VITALITY SPORTS CHIROPRACTIC
Entity type:Organization
Organization Name:VITALITY SPORTS CHIROPRACTIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:WISKIND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-431-4853
Mailing Address - Street 1:139 NORCROSS ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3867
Mailing Address - Country:US
Mailing Address - Phone:678-321-1710
Mailing Address - Fax:678-321-1711
Practice Address - Street 1:139 NORCROSS ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3867
Practice Address - Country:US
Practice Address - Phone:678-321-1710
Practice Address - Fax:678-321-1710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008042111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty