Provider Demographics
NPI:1760741698
Name:VITALITY WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:VITALITY WELLNESS CLINIC LLC
Other - Org Name:VITALITY MEDICAL CLINIC AND SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:CROWDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-591-9769
Mailing Address - Street 1:3200 MALLETT RD
Mailing Address - Street 2:SUITE D-3
Mailing Address - City:D'IBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-9305
Mailing Address - Country:US
Mailing Address - Phone:228-392-0900
Mailing Address - Fax:228-392-0902
Practice Address - Street 1:3200 MALLETT RD
Practice Address - Street 2:D-3
Practice Address - City:D'IBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-9305
Practice Address - Country:US
Practice Address - Phone:228-392-0900
Practice Address - Fax:228-392-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-12
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20041174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty