Provider Demographics
NPI:1043858012
Name:MEDICAL VITALITY CLINIC LLC
Entity Type:Organization
Organization Name:MEDICAL VITALITY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICAL
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-279-2276
Mailing Address - Street 1:1845 CORDOVA RD STE 204
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-6100
Mailing Address - Country:US
Mailing Address - Phone:954-361-3343
Mailing Address - Fax:
Practice Address - Street 1:1845 CORDOVA RD STE 204
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-6100
Practice Address - Country:US
Practice Address - Phone:954-361-3343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty