Provider Demographics
NPI:1588904270
Name:VITALITY ME
Entity type:Organization
Organization Name:VITALITY ME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:L
Authorized Official - Last Name:KEEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-886-0818
Mailing Address - Street 1:300 N COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2619
Mailing Address - Country:US
Mailing Address - Phone:920-886-0818
Mailing Address - Fax:920-886-0573
Practice Address - Street 1:300 N COMMERCIAL ST
Practice Address - Street 2:SUITE 2
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2619
Practice Address - Country:US
Practice Address - Phone:920-886-0818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI421430202261Q00000X
WI42143020261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42143-020OtherLICENSE NUMBER