1710347737 NPI number — VITALITY WEIGHT LOSS AND WELLNESS INSTITUTE, PLLC

Table of content: (NPI 1710347737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710347737 NPI number — VITALITY WEIGHT LOSS AND WELLNESS INSTITUTE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITALITY WEIGHT LOSS AND WELLNESS INSTITUTE, PLLC
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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1710347737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5760 LEGACY DR
Provider Second Line Business Mailing Address:
STE B3-424
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75024-7102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-314-2930
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6201 DALLAS PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-597-1639
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
RUBY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MEMBER MANAGER
Authorized Official Telephone Number:
951-314-2930

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  Q6034 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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