Provider Demographics
NPI:1275147308
Name:VITALITY PEDIATRIC HEALTHCARE,LLC
Entity Type:Organization
Organization Name:VITALITY PEDIATRIC HEALTHCARE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:EYAKOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-346-0097
Mailing Address - Street 1:3822 BASTROP ST
Mailing Address - Street 2:
Mailing Address - City:MELISSA
Mailing Address - State:TX
Mailing Address - Zip Code:75454-1402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3822 BASTROP ST
Practice Address - Street 2:
Practice Address - City:MELISSA
Practice Address - State:TX
Practice Address - Zip Code:75454-1402
Practice Address - Country:US
Practice Address - Phone:469-346-0097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-05
Last Update Date:2020-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health