Provider Demographics
NPI:1689430407
Name:VITALITY HEALTH CLINIC PLLC
Entity Type:Organization
Organization Name:VITALITY HEALTH CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:RAWYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZAN
Authorized Official - Suffix:
Authorized Official - Credentials:AGPCNP-BC
Authorized Official - Phone:313-414-0703
Mailing Address - Street 1:4245 S BEECH DALY ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48125-1576
Mailing Address - Country:US
Mailing Address - Phone:313-414-0703
Mailing Address - Fax:
Practice Address - Street 1:4245 S BEECH DALY ST STE 102
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48125-1576
Practice Address - Country:US
Practice Address - Phone:313-414-0703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-28
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center