Provider Demographics
NPI:1407597230
Name:VITAM FLORIDA HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:VITAM FLORIDA HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:KANOULD
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLCINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-310-1567
Mailing Address - Street 1:11352 SW WYNDHAM WAY
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2784
Mailing Address - Country:US
Mailing Address - Phone:772-310-1567
Mailing Address - Fax:
Practice Address - Street 1:130 S INDIAN RIVER DR STE 202
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4353
Practice Address - Country:US
Practice Address - Phone:772-310-1567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty