Provider Demographics
NPI:1073257614
Name:VITELLARIA LLC
Entity Type:Organization
Organization Name:VITELLARIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:503-781-3278
Mailing Address - Street 1:7084 SW 181ST PL
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-5252
Mailing Address - Country:US
Mailing Address - Phone:503-781-3278
Mailing Address - Fax:
Practice Address - Street 1:9735 SW SHADY LN STE 104
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5481
Practice Address - Country:US
Practice Address - Phone:503-707-6302
Practice Address - Fax:503-747-4023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-20
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)