Provider Demographics
NPI:1467180299
Name:VITALIZED PERFORMANCE GROUP
Entity Type:Organization
Organization Name:VITALIZED PERFORMANCE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GORICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MLADEN-ADDUCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-560-0249
Mailing Address - Street 1:212 NEW LONDON TPKE STE D
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4202
Mailing Address - Country:US
Mailing Address - Phone:860-430-2342
Mailing Address - Fax:
Practice Address - Street 1:212 NEW LONDON TPKE STE D
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4202
Practice Address - Country:US
Practice Address - Phone:860-430-2342
Practice Address - Fax:860-430-2342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1427201540Medicaid
CT1609232081Medicaid
CT1992858583Medicaid