1912445073 NPI number — VITALITY UNLIMITED

Table of content: (NPI 1912445073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912445073 NPI number — VITALITY UNLIMITED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITALITY UNLIMITED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VITALITY UNLIMITED
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912445073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2580
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89803-2580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-738-4158
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3740 E IDAHO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89801-4611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-738-4158
Provider Business Practice Location Address Fax Number:
775-753-6487
Provider Enumeration Date:
02/08/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DEXTER
Authorized Official First Name:
DOROTHY
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
775-738-4158

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1376624494 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".