Provider Demographics
NPI:1083965792
Name:VITAL FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:VITAL FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:IKEDA
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:206-518-8939
Mailing Address - Street 1:3513 NE 45TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-5665
Mailing Address - Country:US
Mailing Address - Phone:206-518-8938
Mailing Address - Fax:206-525-3273
Practice Address - Street 1:3513 NE 45TH ST STE 2
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5665
Practice Address - Country:US
Practice Address - Phone:206-518-8938
Practice Address - Fax:206-525-3273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603118032261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty