Provider Demographics
NPI:1215585807
Name:VITEGENT HEALTHCARE INC.
Entity Type:Organization
Organization Name:VITEGENT HEALTHCARE INC.
Other - Org Name:PETRIFIED FOREST MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-724-6217
Mailing Address - Street 1:8 THE GRN STE 10294
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-3618
Mailing Address - Country:US
Mailing Address - Phone:302-724-6217
Mailing Address - Fax:
Practice Address - Street 1:500 E IOWA ST
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025-2750
Practice Address - Country:US
Practice Address - Phone:928-524-3913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-28
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy