Provider Demographics
NPI:1629420005
Name:VITAL MEDICAL EQUIPMENT
Entity Type:Organization
Organization Name:VITAL MEDICAL EQUIPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VALDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-782-9327
Mailing Address - Street 1:11715 FAIRFAX WOODS WAY APT 9103
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-8345
Mailing Address - Country:US
Mailing Address - Phone:703-782-9327
Mailing Address - Fax:703-782-9365
Practice Address - Street 1:6399 LITTLE RIVER TPKE
Practice Address - Street 2:STE 201
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312-5093
Practice Address - Country:US
Practice Address - Phone:703-782-9327
Practice Address - Fax:703-782-9365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-08
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1720526332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1720526Medicaid