Provider Demographics
NPI:1396123733
Name:VITAL HEALTH CARE LLC
Entity type:Organization
Organization Name:VITAL HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-218-1515
Mailing Address - Street 1:7707 W DEER VALLEY RD STE 115
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2101
Mailing Address - Country:US
Mailing Address - Phone:623-218-1515
Mailing Address - Fax:623-399-9958
Practice Address - Street 1:7707 W DEER VALLEY RD STE 115
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2101
Practice Address - Country:US
Practice Address - Phone:623-218-1515
Practice Address - Fax:623-399-9958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2747207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2747OtherLICENSE