Provider Demographics
NPI:1710427174
Name:VITALITY AESTHETICS PLLC
Entity Type:Organization
Organization Name:VITALITY AESTHETICS PLLC
Other - Org Name:VITALITY AESTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-502-9779
Mailing Address - Street 1:7680 GODDARD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-8235
Mailing Address - Country:US
Mailing Address - Phone:719-502-9779
Mailing Address - Fax:719-418-6172
Practice Address - Street 1:7680 GODDARD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-8235
Practice Address - Country:US
Practice Address - Phone:719-502-9779
Practice Address - Fax:719-418-6172
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WOODLAND PARK FAMILY MEDICINE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty