Provider Demographics
NPI:1497261952
Name:VITA WELLNESS LLC
Entity Type:Organization
Organization Name:VITA WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:KREHBIEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-726-2701
Mailing Address - Street 1:2117 N KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-3908
Mailing Address - Country:US
Mailing Address - Phone:405-726-2701
Mailing Address - Fax:405-726-2702
Practice Address - Street 1:2117 N KELLY AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3908
Practice Address - Country:US
Practice Address - Phone:405-726-2701
Practice Address - Fax:405-726-2702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty