Provider Demographics
NPI:1992458285
Name:VITAL HEALING FUNCTIONAL MEDICINE, LLC
Entity type:Organization
Organization Name:VITAL HEALING FUNCTIONAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORANS
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:605-472-0404
Mailing Address - Street 1:1760 CENTRE ST STE B
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-4035
Mailing Address - Country:US
Mailing Address - Phone:605-872-0404
Mailing Address - Fax:605-472-7304
Practice Address - Street 1:1760 CENTRE ST STE B
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57703-4035
Practice Address - Country:US
Practice Address - Phone:605-872-0404
Practice Address - Fax:605-472-7304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-27
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service