Provider Demographics
NPI:1417647066
Name:VITAL FAMILY HEALTHCARE LLC.
Entity Type:Organization
Organization Name:VITAL FAMILY HEALTHCARE LLC.
Other - Org Name:CLINIC OF BELVIDERE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-653-3496
Mailing Address - Street 1:1004 LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008
Mailing Address - Country:US
Mailing Address - Phone:815-482-6365
Mailing Address - Fax:
Practice Address - Street 1:1004 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008
Practice Address - Country:US
Practice Address - Phone:815-482-6365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-08
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty