Provider Demographics
NPI:1528761145
Name:PREMIER VITALITY IV AND WELLNESS CENTER
Entity type:Organization
Organization Name:PREMIER VITALITY IV AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-442-6553
Mailing Address - Street 1:902 COOKS BAY CT
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1612
Mailing Address - Country:US
Mailing Address - Phone:773-304-7818
Mailing Address - Fax:
Practice Address - Street 1:10715 CHARTER DR STE 270
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2871
Practice Address - Country:US
Practice Address - Phone:410-442-6553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center