Provider Demographics
NPI:1114189669
Name:VITAL PROSTHETICS, INC.
Entity Type:Organization
Organization Name:VITAL PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:E
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:CP
Authorized Official - Phone:850-526-0063
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32447-0430
Mailing Address - Country:US
Mailing Address - Phone:850-526-0063
Mailing Address - Fax:850-526-1317
Practice Address - Street 1:4299 3RD AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2136
Practice Address - Country:US
Practice Address - Phone:850-526-0063
Practice Address - Fax:850-526-1317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPRO 66335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6109260001Medicare NSC