Provider Demographics
NPI:1659409860
Name:VITA LIFE MEDICAL LLC
Entity Type:Organization
Organization Name:VITA LIFE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LUKE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-387-6498
Mailing Address - Street 1:2870 PEACHTREE RD NE
Mailing Address - Street 2:STE 431
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:678-387-6498
Mailing Address - Fax:
Practice Address - Street 1:2870 PEACHTREE RD NE
Practice Address - Street 2:STE 431
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305
Practice Address - Country:US
Practice Address - Phone:678-387-6498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0318572081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty