Provider Demographics
NPI:1386176634
Name:VITALE, STEFANO (DOM, LAC)
Entity type:Individual
Prefix:
First Name:STEFANO
Middle Name:
Last Name:VITALE
Suffix:
Gender:M
Credentials:DOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 WOODDUCK LN
Mailing Address - Street 2:
Mailing Address - City:BLANCH
Mailing Address - State:NC
Mailing Address - Zip Code:27212-9599
Mailing Address - Country:US
Mailing Address - Phone:910-817-4449
Mailing Address - Fax:
Practice Address - Street 1:502 WOODDUCK LN
Practice Address - Street 2:
Practice Address - City:BLANCH
Practice Address - State:NC
Practice Address - Zip Code:27212-9599
Practice Address - Country:US
Practice Address - Phone:910-817-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19171100000X
NM367171100000X
VA0121000823171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist