Provider Demographics
NPI:1598229536
Name:FLORIDA MENS VITALITY CENTER INC
Entity Type:Organization
Organization Name:FLORIDA MENS VITALITY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DEJOHN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:239-220-1083
Mailing Address - Street 1:28901 TRAILS EDGE BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-7588
Mailing Address - Country:US
Mailing Address - Phone:239-220-1083
Mailing Address - Fax:
Practice Address - Street 1:28901 TRAILS EDGE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-7588
Practice Address - Country:US
Practice Address - Phone:239-220-1083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty