Provider Demographics
NPI:1427428887
Name:VITALGENIX HEALTH & WELLNESS, LLC
Entity type:Organization
Organization Name:VITALGENIX HEALTH & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:TAMAYO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-636-9663
Mailing Address - Street 1:1325 S INTERNATIONAL PKWY
Mailing Address - Street 2:SUITE 2241
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1695
Mailing Address - Country:US
Mailing Address - Phone:407-636-9663
Mailing Address - Fax:407-636-9664
Practice Address - Street 1:1325 S INTERNATIONAL PKWY
Practice Address - Street 2:SUITE 2241
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1695
Practice Address - Country:US
Practice Address - Phone:407-636-9663
Practice Address - Fax:407-636-9664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD50997Medicare UPIN