Provider Demographics
NPI:1104285725
Name:VITAL ORTHOPEDIC & SPINE INSTITUTE, INC
Entity type:Organization
Organization Name:VITAL ORTHOPEDIC & SPINE INSTITUTE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MISSIRIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-848-2507
Mailing Address - Street 1:1730 S FEDERAL HWY # 199
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33483-3309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4848 COCONUT CREEK PKWY # 200
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33063-3904
Practice Address - Country:US
Practice Address - Phone:877-848-2507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114632174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty