Provider Demographics
NPI:1619103587
Name:HEALTH AND VITALITY CENTER MEDICAL CORPORATION
Entity Type:Organization
Organization Name:HEALTH AND VITALITY CENTER MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:LALEZAR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-477-1166
Mailing Address - Street 1:11600 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5781
Mailing Address - Country:US
Mailing Address - Phone:310-477-1166
Mailing Address - Fax:310-477-9911
Practice Address - Street 1:11600 WILSHIRE BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5781
Practice Address - Country:US
Practice Address - Phone:310-477-1166
Practice Address - Fax:310-477-9911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty