Provider Demographics
NPI:1962930503
Name:VITALITY MEDICAL
Entity type:Organization
Organization Name:VITALITY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NIKO
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLIASTASIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-636-3930
Mailing Address - Street 1:209 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-4639
Mailing Address - Country:US
Mailing Address - Phone:918-503-6276
Mailing Address - Fax:918-503-6294
Practice Address - Street 1:209 N OAK ST
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-4639
Practice Address - Country:US
Practice Address - Phone:918-636-3930
Practice Address - Fax:888-422-2115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-26
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care