Provider Demographics
NPI:1225605157
Name:VITALITY INTEGRATIVE MEDICINE LLC
Entity Type:Organization
Organization Name:VITALITY INTEGRATIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LICCIARDO
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:732-245-5645
Mailing Address - Street 1:46 LEBANON RD UNIT 5A
Mailing Address - Street 2:
Mailing Address - City:BOZRAH
Mailing Address - State:CT
Mailing Address - Zip Code:06334-1116
Mailing Address - Country:US
Mailing Address - Phone:860-800-2240
Mailing Address - Fax:833-913-2431
Practice Address - Street 1:46 LEBANON RD UNIT 5A
Practice Address - Street 2:
Practice Address - City:BOZRAH
Practice Address - State:CT
Practice Address - Zip Code:06334-1116
Practice Address - Country:US
Practice Address - Phone:860-800-2240
Practice Address - Fax:833-913-2431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty