Provider Demographics
NPI:1477035558
Name:VITAL WELLNESS HEALTHCARE, INC.
Entity Type:Organization
Organization Name:VITAL WELLNESS HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NELIA
Authorized Official - Middle Name:LAUREL-
Authorized Official - Last Name:LADLAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-332-9568
Mailing Address - Street 1:1717 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3735
Mailing Address - Country:US
Mailing Address - Phone:773-332-9568
Mailing Address - Fax:773-345-4637
Practice Address - Street 1:2621 MONTEGA DR STE E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7002
Practice Address - Country:US
Practice Address - Phone:312-989-9260
Practice Address - Fax:773-345-4637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-05
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1010318251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1010318Medicaid