Provider Demographics
NPI:1366136814
Name:VITALITY INTEGRATED MEDICAL NETWORK LLC
Entity type:Organization
Organization Name:VITALITY INTEGRATED MEDICAL NETWORK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-906-9536
Mailing Address - Street 1:PO BOX 8929
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33075-8929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 18TH ST STE 102
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-0824
Practice Address - Country:US
Practice Address - Phone:772-562-6818
Practice Address - Fax:772-299-3653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-07
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion TherapyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty