1316277171 NPI number — VITALE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316277171 NPI number — VITALE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITALE
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:
Provider Other Organization Name Type Code:
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:
1316277171
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1118 11TH ST
Provider Second Line Business Mailing Address:
STE. 6
Provider Business Mailing Address City Name:
SANTA MONICA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90403-5318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-795-5854
Provider Business Mailing Address Fax Number:
323-766-1103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1118 11TH ST
Provider Second Line Business Practice Location Address:
STE. 6
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90403-5318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-795-5854
Provider Business Practice Location Address Fax Number:
323-766-1103
Provider Enumeration Date:
12/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WOZNIAK
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-795-5854

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN680091 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385H00000X , with the licence number: RN680091 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 002449639-0001-1 . This is a "BUSINESS LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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