Provider Demographics
NPI:1386289585
Name:VITAL DERMATOLOGY LLC
Entity type:Organization
Organization Name:VITAL DERMATOLOGY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-888-2424
Mailing Address - Street 1:6202 N 9TH AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8291
Mailing Address - Country:US
Mailing Address - Phone:850-888-2424
Mailing Address - Fax:620-710-7703
Practice Address - Street 1:6202 N 9TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8291
Practice Address - Country:US
Practice Address - Phone:850-888-2424
Practice Address - Fax:620-710-7703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-12
Last Update Date:2020-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty