Provider Demographics
NPI:1063144947
Name:VITAL HEALTH MED GROUP INC
Entity type:Organization
Organization Name:VITAL HEALTH MED GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:LESSETT
Authorized Official - Last Name:MARQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-333-4896
Mailing Address - Street 1:5237 PREMIERE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-2715
Mailing Address - Country:US
Mailing Address - Phone:424-333-4896
Mailing Address - Fax:
Practice Address - Street 1:350 W 5TH ST STE 105-B
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2737
Practice Address - Country:US
Practice Address - Phone:424-333-4896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical ExaminerGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty