Provider Demographics
NPI:1821543208
Name:VITALITY WEIGHT LOSS AND WELLNESS INSTITUTE, PLLC
Entity Type:Organization
Organization Name:VITALITY WEIGHT LOSS AND WELLNESS INSTITUTE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RUBY
Authorized Official - Middle Name:JAIN
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-314-2930
Mailing Address - Street 1:5760 LEGACY DR STE B3-424
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-7102
Mailing Address - Country:US
Mailing Address - Phone:972-737-3296
Mailing Address - Fax:
Practice Address - Street 1:2633 DALLAS PKWY # 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4703
Practice Address - Country:US
Practice Address - Phone:972-737-3296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6034207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty