Provider Demographics
NPI:1992315659
Name:VITAL HEALTH PRIMARY CARE LLC
Entity type:Organization
Organization Name:VITAL HEALTH PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNATORY
Authorized Official - Prefix:
Authorized Official - First Name:JESSLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEX
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:215-738-2072
Mailing Address - Street 1:293 PHEASANT DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-3036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:930 HENRIETTA AVE STE C
Practice Address - Street 2:
Practice Address - City:HUNTINGDON VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19006-8523
Practice Address - Country:US
Practice Address - Phone:215-663-9380
Practice Address - Fax:215-663-9383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-06
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care