Provider Demographics
NPI:1831639954
Name:VITALCARE MEDICAL, LLC
Entity Type:Organization
Organization Name:VITALCARE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMICA
Authorized Official - Middle Name:SHEILA
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:973-985-8382
Mailing Address - Street 1:PO BOX 8210
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-8210
Mailing Address - Country:US
Mailing Address - Phone:973-985-8382
Mailing Address - Fax:
Practice Address - Street 1:34 UNION AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3219
Practice Address - Country:US
Practice Address - Phone:973-985-8382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00486800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0417106Medicaid
NJ472728ZP1NMedicare PIN