Provider Demographics
NPI:1265882435
Name:VITLAITY CHIRORPACTIC AND WELLNESS INC
Entity type:Organization
Organization Name:VITLAITY CHIRORPACTIC AND WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:DERENZO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:906-553-1106
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:21 TRIMOUNTAIN AVE
Mailing Address - City:SOUTH RANGE
Mailing Address - State:MI
Mailing Address - Zip Code:49963
Mailing Address - Country:US
Mailing Address - Phone:906-553-1106
Mailing Address - Fax:
Practice Address - Street 1:21 TRIMOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RANGE
Practice Address - State:MI
Practice Address - Zip Code:49963
Practice Address - Country:US
Practice Address - Phone:906-553-1106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010420261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care