Provider Demographics
NPI:1467196402
Name:VITALS HEALTHCARE SVCS
Entity Type:Organization
Organization Name:VITALS HEALTHCARE SVCS
Other - Org Name:VITALS HEALTHCARE SVCS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PHEDRE
Authorized Official - Middle Name:PHARA
Authorized Official - Last Name:PAULEMON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:917-907-0797
Mailing Address - Street 1:2525 NOSTRAND AVENUE APT 2C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-4715
Mailing Address - Country:US
Mailing Address - Phone:917-907-0797
Mailing Address - Fax:917-933-4212
Practice Address - Street 1:2525 NOSTRAND AVENUE
Practice Address - Street 2:APT 2C
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-4715
Practice Address - Country:US
Practice Address - Phone:917-907-0797
Practice Address - Fax:917-933-4212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05401478Medicaid