Provider Demographics
NPI:1386909331
Name:VITAE FAMILY CARE CLINIC, L.L.C.
Entity type:Organization
Organization Name:VITAE FAMILY CARE CLINIC, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/MANAGER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:CARTER
Authorized Official - Last Name:MCKERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:641-203-3548
Mailing Address - Street 1:1355 50TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1617
Mailing Address - Country:US
Mailing Address - Phone:515-225-3261
Mailing Address - Fax:515-225-1944
Practice Address - Street 1:1355 50TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1617
Practice Address - Country:US
Practice Address - Phone:515-225-3261
Practice Address - Fax:515-225-1944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-05
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02827207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty