1528233780 NPI number — VITAL ENTERPRISES, INC.

Table of content: (NPI 1528233780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528233780 NPI number — VITAL ENTERPRISES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITAL ENTERPRISES, INC.
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:
1528233780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100330
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-0330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-913-9106
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1013 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01603-2426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-757-9111
Provider Business Practice Location Address Fax Number:
508-753-1284
Provider Enumeration Date:
04/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP OF REVENUE MANAGEMENT
Authorized Official Telephone Number:
833-703-2294

Provider Taxonomy Codes

  • Taxonomy code: 341600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 110080397A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: MCD008002896 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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