Provider Demographics
NPI:1710517347
Name:VITAL MED LLC
Entity Type:Organization
Organization Name:VITAL MED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NP
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:HAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:662-368-3858
Mailing Address - Street 1:103 RIDGEMONT VILLA
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-1010
Mailing Address - Country:US
Mailing Address - Phone:662-368-3858
Mailing Address - Fax:662-368-3931
Practice Address - Street 1:103 RIDGEMONT VILLA
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-1010
Practice Address - Country:US
Practice Address - Phone:662-368-3858
Practice Address - Fax:662-368-3931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02056754Medicaid