Provider Demographics
NPI:1558959247
Name:VITALITY WELLNESS AND MEDSPA PLLC
Entity Type:Organization
Organization Name:VITALITY WELLNESS AND MEDSPA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KOMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-549-0252
Mailing Address - Street 1:24464 THATCHER DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2365
Mailing Address - Country:US
Mailing Address - Phone:617-549-0252
Mailing Address - Fax:
Practice Address - Street 1:24464 THATCHER DR
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2365
Practice Address - Country:US
Practice Address - Phone:617-549-0252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty