Provider Demographics
NPI:1518673433
Name:VIETRULIFE MEDICAL SPA CORP
Entity Type:Organization
Organization Name:VIETRULIFE MEDICAL SPA CORP
Other - Org Name:VIETRULIFE MEDICAL SPA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-333-2573
Mailing Address - Street 1:3772 EAGLE ISLE CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-1907
Mailing Address - Country:US
Mailing Address - Phone:321-333-2573
Mailing Address - Fax:
Practice Address - Street 1:216 BROADWAY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5768
Practice Address - Country:US
Practice Address - Phone:407-910-4040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty