Provider Demographics
NPI:1932861390
Name:VITAL WELL LLC
Entity type:Organization
Organization Name:VITAL WELL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:VITALE
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CDCES
Authorized Official - Phone:808-595-6237
Mailing Address - Street 1:3939 VESELICH AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-1485
Mailing Address - Country:US
Mailing Address - Phone:808-595-6237
Mailing Address - Fax:
Practice Address - Street 1:3939 VESELICH AVE APT 302
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-1485
Practice Address - Country:US
Practice Address - Phone:808-595-6237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VITAL WELL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty