Provider Demographics
NPI:1417598517
Name:VITALIS HEALTH
Entity Type:Organization
Organization Name:VITALIS HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:423-902-9667
Mailing Address - Street 1:3091 BATTLEFIELD PKWY
Mailing Address - Street 2:
Mailing Address - City:FT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-4003
Mailing Address - Country:US
Mailing Address - Phone:706-841-0500
Mailing Address - Fax:
Practice Address - Street 1:3091 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4003
Practice Address - Country:US
Practice Address - Phone:423-902-9667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-01
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)