Provider Demographics
NPI:1164004768
Name:VITAL WELL
Entity Type:Organization
Organization Name:VITAL WELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:VITALE
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CDCES
Authorized Official - Phone:808-595-6237
Mailing Address - Street 1:3939 VESELICH AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-1485
Mailing Address - Country:US
Mailing Address - Phone:808-595-6237
Mailing Address - Fax:
Practice Address - Street 1:3939 VESELICH AVE APT 302
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-1485
Practice Address - Country:US
Practice Address - Phone:808-595-6237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1114366002Medicaid