1386246858 NPI number — VITALITY DX LLC

Table of content: (NPI 1386246858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386246858 NPI number — VITALITY DX LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITALITY DX LLC
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:
6
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:
1386246858
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7145 E VIRGINIA ST STE 2000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47715-9147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-962-7894
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2277 THUNDERSTICK DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40505-4882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-830-9503
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/10/2020

Additional Information

Authorized Official

Authorized Official Last Name:
FISHER
Authorized Official First Name:
TAMIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
812-962-7894

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100719120 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 18D2200531 . This is a "CLIA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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