Provider Demographics
NPI:1467661157
Name:VITALSURGE LLC
Entity Type:Organization
Organization Name:VITALSURGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DICK
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-206-0105
Mailing Address - Street 1:702 W 42ND ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4564
Mailing Address - Country:US
Mailing Address - Phone:417-206-0105
Mailing Address - Fax:417-206-0109
Practice Address - Street 1:702 W 42ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4564
Practice Address - Country:US
Practice Address - Phone:417-206-0105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site