Provider Demographics
NPI:1891450250
Name:VITABOOST WELLNESS
Entity Type:Organization
Organization Name:VITABOOST WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDRA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-877-8067
Mailing Address - Street 1:20955 DEVONSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-2313
Mailing Address - Country:US
Mailing Address - Phone:310-877-8067
Mailing Address - Fax:818-280-3874
Practice Address - Street 1:20955 DEVONSHIRE ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-2313
Practice Address - Country:US
Practice Address - Phone:310-877-8067
Practice Address - Fax:818-280-3874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy