Provider Demographics
NPI:1962133272
Name:VIBRANT DIAGNOSTICS LLC
Entity type:Organization
Organization Name:VIBRANT DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHIANDRA
Authorized Official - Middle Name:KEYATA
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-373-8284
Mailing Address - Street 1:108 TIMBERLAKE DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-9309
Mailing Address - Country:US
Mailing Address - Phone:843-373-8284
Mailing Address - Fax:
Practice Address - Street 1:514 2ND LOOP RD STE D
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-2848
Practice Address - Country:US
Practice Address - Phone:843-373-8284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-19
Last Update Date:2022-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center