Provider Demographics
NPI:1962779850
Name:VITALITY FOR LIFE
Entity type:Organization
Organization Name:VITALITY FOR LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-782-1586
Mailing Address - Street 1:1107 US HIGHWAY 395 N
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89410-5304
Mailing Address - Country:US
Mailing Address - Phone:775-782-1599
Mailing Address - Fax:775-782-1558
Practice Address - Street 1:1107 US HIGHWAY 395 N
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5304
Practice Address - Country:US
Practice Address - Phone:775-782-1599
Practice Address - Fax:775-782-1558
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARSON VALLEY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10804261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health