Provider Demographics
NPI:1821490335
Name:VITANOVU, P.C.
Entity Type:Organization
Organization Name:VITANOVU, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENIFER
Authorized Official - Middle Name:LEAH
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-344-8482
Mailing Address - Street 1:1525 S OWYHEE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-6014
Mailing Address - Country:US
Mailing Address - Phone:208-344-8482
Mailing Address - Fax:208-345-5426
Practice Address - Street 1:1525 S OWYHEE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-6014
Practice Address - Country:US
Practice Address - Phone:208-344-8482
Practice Address - Fax:208-345-5426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11233261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center