Provider Demographics
NPI:1609065622
Name:VITA O2 INC.
Entity Type:Organization
Organization Name:VITA O2 INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERE
Authorized Official - Middle Name:
Authorized Official - Last Name:HYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-265-8952
Mailing Address - Street 1:90 CHAPPELL RD
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-7497
Mailing Address - Country:US
Mailing Address - Phone:706-265-8952
Mailing Address - Fax:706-265-8953
Practice Address - Street 1:104 COLONY PARK DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2792
Practice Address - Country:US
Practice Address - Phone:706-265-8952
Practice Address - Fax:706-265-8953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities