Provider Demographics
NPI:1659720936
Name:VIBRANT HEALTH PC
Entity Type:Organization
Organization Name:VIBRANT HEALTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FATIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-782-9384
Mailing Address - Street 1:12202 DEER MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:KAMAS
Mailing Address - State:UT
Mailing Address - Zip Code:84036
Mailing Address - Country:US
Mailing Address - Phone:435-604-0594
Mailing Address - Fax:847-919-8661
Practice Address - Street 1:1910 PROSPECTOR AVE SUITE 302
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060
Practice Address - Country:US
Practice Address - Phone:435-604-0594
Practice Address - Fax:847-919-8661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097212207L00000X
UT10369621-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty