Provider Demographics
NPI:1497017974
Name:VITAL KIDS MEDICINE
Entity Type:Organization
Organization Name:VITAL KIDS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MANAGER/ MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:HATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GBEDAWO
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:206-518-8938
Mailing Address - Street 1:5122 25TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-4121
Mailing Address - Country:US
Mailing Address - Phone:206-518-8938
Mailing Address - Fax:
Practice Address - Street 1:5122 25TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4121
Practice Address - Country:US
Practice Address - Phone:206-518-8938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT00001229261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care