Provider Demographics
NPI:1427331982
Name:VITALITY MENS HEALTH AND WELLNESS, LLC
Entity type:Organization
Organization Name:VITALITY MENS HEALTH AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-737-1992
Mailing Address - Street 1:6655 POPLAR AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3691
Mailing Address - Country:US
Mailing Address - Phone:901-751-4477
Mailing Address - Fax:901-751-4488
Practice Address - Street 1:6655 POPLAR AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3691
Practice Address - Country:US
Practice Address - Phone:901-751-4477
Practice Address - Fax:901-751-4488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46215207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty