Provider Demographics
NPI:1174255038
Name:VITALITY DX LLC
Entity Type:Organization
Organization Name:VITALITY DX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TAMIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-962-7890
Mailing Address - Street 1:2211 GREENE WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-4076
Mailing Address - Country:US
Mailing Address - Phone:812-962-7890
Mailing Address - Fax:
Practice Address - Street 1:7145 E VIRGINIA ST STE 4000
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-9145
Practice Address - Country:US
Practice Address - Phone:812-962-7890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory