Provider Demographics
NPI:1184198442
Name:VITALITY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:VITALITY MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:LILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEROBIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-805-0005
Mailing Address - Street 1:1648 W GLENOAKS BLVD # 101
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-1827
Mailing Address - Country:US
Mailing Address - Phone:818-805-0005
Mailing Address - Fax:818-805-0050
Practice Address - Street 1:1648 W GLENOAKS BLVD # 101
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-1827
Practice Address - Country:US
Practice Address - Phone:818-805-0005
Practice Address - Fax:818-805-0050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC4208588OtherCORPORATION NUMBER