Provider Demographics
NPI:1346081304
Name:VITAL HEALTH ALLIANCE GROUP
Entity type:Organization
Organization Name:VITAL HEALTH ALLIANCE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:918-961-1658
Mailing Address - Street 1:828 A ST NW
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-4605
Mailing Address - Country:US
Mailing Address - Phone:918-961-1658
Mailing Address - Fax:
Practice Address - Street 1:828 A ST NW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-4605
Practice Address - Country:US
Practice Address - Phone:918-961-1658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-04
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care