Provider Demographics
NPI:1508206442
Name:VITALITY CLINICS OF EAST TEXAS, P.A.
Entity Type:Organization
Organization Name:VITALITY CLINICS OF EAST TEXAS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:KIP
Authorized Official - Last Name:YODER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-525-9432
Mailing Address - Street 1:455 RICE RD
Mailing Address - Street 2:102
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3604
Mailing Address - Country:US
Mailing Address - Phone:903-525-9432
Mailing Address - Fax:903-525-9455
Practice Address - Street 1:455 RICE RD
Practice Address - Street 2:102
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3604
Practice Address - Country:US
Practice Address - Phone:903-525-9432
Practice Address - Fax:903-525-9455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty