Provider Demographics
NPI:1720355621
Name:MUJICA TRENCHE - VITALITY MD PC
Entity type:Organization
Organization Name:MUJICA TRENCHE - VITALITY MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MUJICA TRENCHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-888-0052
Mailing Address - Street 1:PO BOX 521
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-0521
Mailing Address - Country:US
Mailing Address - Phone:316-927-3884
Mailing Address - Fax:
Practice Address - Street 1:6380 W FLAMINGO RD
Practice Address - Street 2:STE A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-7129
Practice Address - Country:US
Practice Address - Phone:702-888-0052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-19
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty