1578702411 NPI number — VITAL IMAGE HEALTH, LLC

Table of content: (NPI 1578702411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578702411 NPI number — VITAL IMAGE HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITAL IMAGE HEALTH, 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:
VITAL IMAGE MED SPA AND ANTI-AGING
Provider Other Organization Name Type Code:
3
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:
1578702411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 GLADES RD
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33431-6421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-392-0034
Provider Business Mailing Address Fax Number:
800-928-7109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 GLADES RD
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33431-6421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-392-0034
Provider Business Practice Location Address Fax Number:
800-928-7109
Provider Enumeration Date:
02/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GARCIA
Authorized Official First Name:
ANGEL
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
561-392-0034

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  ME42709 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X , with the licence number: ME42709 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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