1942456082 NPI number — VITALITY SPORTS MEDICINE, INC.

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 1942456082 NPI number — VITALITY SPORTS MEDICINE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITALITY SPORTS MEDICINE, 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:
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:
1942456082
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 260172
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75026-0172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-867-2900
Provider Business Mailing Address Fax Number:
972-867-2902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2004 VENTURA DR
Provider Second Line Business Practice Location Address:
#250
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-2001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-867-2900
Provider Business Practice Location Address Fax Number:
972-867-2902
Provider Enumeration Date:
08/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FORD
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
JOE
Authorized Official Title or Position:
OWNER/ DOCTOR
Authorized Official Telephone Number:
972-867-2900

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  7844 , 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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