Provider Demographics
NPI:1790484194
Name:VITALITY PLUS UROLOGY, LLC
Entity Type:Organization
Organization Name:VITALITY PLUS UROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-232-5215
Mailing Address - Street 1:140 HIGHWAY 201 N
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3158
Mailing Address - Country:US
Mailing Address - Phone:870-232-5215
Mailing Address - Fax:870-232-5240
Practice Address - Street 1:19 MEDICAL PLZ STE 40
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2962
Practice Address - Country:US
Practice Address - Phone:870-232-5215
Practice Address - Fax:870-232-5240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-24
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty