Provider Demographics
NPI:1164151700
Name:OC VITALITY
Entity Type:Organization
Organization Name:OC VITALITY
Other - Org Name:OC VITALITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIMITRI
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUER
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM, LAC
Authorized Official - Phone:949-632-6678
Mailing Address - Street 1:8215 E SOMERSET LN
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92808-2315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 S CHAPARRAL CT STE 150
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92808-2279
Practice Address - Country:US
Practice Address - Phone:949-215-1957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-08
Last Update Date:2023-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Single Specialty