1548489024 NPI number — VITALANT

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 1548489024 NPI number — VITALANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITALANT
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:
1548489024
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10536 PETER A MCCUEN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATHER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95655-4128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-456-1500
Provider Business Mailing Address Fax Number:
916-366-0791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10536 PETER A MCCUEN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATHER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95655-4128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-456-1500
Provider Business Practice Location Address Fax Number:
916-366-0791
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PERRY
Authorized Official First Name:
TANYA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
480-675-5506

Provider Taxonomy Codes

  • Taxonomy code: 331L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 05D0615608 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ74771Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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