Provider Demographics
NPI:1730880212
Name:VIBRANT LIFE DIRECT CARE, PLLC
Entity type:Organization
Organization Name:VIBRANT LIFE DIRECT CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:JEMISON
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-708-3385
Mailing Address - Street 1:2618 E HIGHWAY 37 STE 100
Mailing Address - Street 2:
Mailing Address - City:TUTTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73089-8479
Mailing Address - Country:US
Mailing Address - Phone:405-376-1381
Mailing Address - Fax:800-488-3294
Practice Address - Street 1:2618 E HIGHWAY 37 STE 100
Practice Address - Street 2:
Practice Address - City:TUTTLE
Practice Address - State:OK
Practice Address - Zip Code:73089-8479
Practice Address - Country:US
Practice Address - Phone:405-376-1381
Practice Address - Fax:800-488-3294
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIBRANT LIFE DIRECT CARE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care