# VITAL LIVING THERAPEUTIC MASSAGE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Vital Living WellSpa
- **Organization subpart:** No

## Provider details

- **NPI number:** 1790151157
- **Authorized official:** JANET CARROLL (OWNER)
- **Authorized official phone:** (260) 436-8807

## Contact information

- **Practice address:** 5111 N BEND DR, FORT WAYNE, IN 46804-1753
- **Practice address phone:** (260) 436-8807
- **Practice address fax:** (260) 436-2767
- **Mailing address:** 5111 N BEND DR, FORT WAYNE, IN 46804-1753
- **Mailing address phone:** (260) 436-8807
- **Mailing address fax:** (260) 436-2767

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 163WM1400X | Nurse Massage Therapist (NMT) | 28057959A | IN | Yes |
| 225700000X | Massage Therapist | MT20901877 | IN | — |

## Other

- **Enumeration date:** 08/19/2015
- **Last updated:** 08/19/2015