Provider Demographics
NPI:1407626989
Name:ADULT VITALITY HEALTHCARE LLC
Entity Type:Organization
Organization Name:ADULT VITALITY HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOBOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-608-0559
Mailing Address - Street 1:2946 CREEKS CROSSING BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-0216
Mailing Address - Country:US
Mailing Address - Phone:863-608-0559
Mailing Address - Fax:
Practice Address - Street 1:7969 OAK RUN CIR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-7253
Practice Address - Country:US
Practice Address - Phone:863-608-0559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty