Provider Demographics
NPI:1730657271
Name:VITALITY AGELESS CENTER LLC
Entity Type:Organization
Organization Name:VITALITY AGELESS CENTER LLC
Other - Org Name:VITALITY AGELESS CENTER LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:YU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-614-6266
Mailing Address - Street 1:1110 SATELLITE BLVD
Mailing Address - Street 2:#403
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4686
Mailing Address - Country:US
Mailing Address - Phone:770-614-6266
Mailing Address - Fax:770-623-9949
Practice Address - Street 1:VITALITY AGELESS CENTER LLC
Practice Address - Street 2:1110 SATELLITE BLVD #403
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4686
Practice Address - Country:US
Practice Address - Phone:770-614-6266
Practice Address - Fax:770-623-9949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-02
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center