Provider Demographics
NPI:1326886854
Name:VETERAN LIFE VITALITY SERVICES LLC
Entity type:Organization
Organization Name:VETERAN LIFE VITALITY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PARRY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:JD, PHD, MSM
Authorized Official - Phone:660-973-6617
Mailing Address - Street 1:206 RICE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64659-9210
Mailing Address - Country:US
Mailing Address - Phone:660-973-6617
Mailing Address - Fax:
Practice Address - Street 1:206 RICE ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:MO
Practice Address - Zip Code:64659-9210
Practice Address - Country:US
Practice Address - Phone:660-973-6617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty