Provider Demographics
NPI:1619224144
Name:VITA MEDICAL CARE CLINIC, PLLC
Entity Type:Organization
Organization Name:VITA MEDICAL CARE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUKISHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:PURDIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-677-9488
Mailing Address - Street 1:2911 BREEZEWOOD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303
Mailing Address - Country:US
Mailing Address - Phone:910-677-9488
Mailing Address - Fax:910-677-9491
Practice Address - Street 1:2911 BREEZEWOOD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303
Practice Address - Country:US
Practice Address - Phone:910-677-9488
Practice Address - Fax:910-677-9491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty