Provider Demographics
NPI:1942456082
Name:VITALITY SPORTS MEDICINE, INC.
Entity Type:Organization
Organization Name:VITALITY SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:FORD
Authorized Official - Suffix:JR
Authorized Official - Credentials:BS, DC, CCSP
Authorized Official - Phone:972-867-2900
Mailing Address - Street 1:PO BOX 260172
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75026-0172
Mailing Address - Country:US
Mailing Address - Phone:972-867-2900
Mailing Address - Fax:972-867-2902
Practice Address - Street 1:2004 VENTURA DR
Practice Address - Street 2:#250
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-2001
Practice Address - Country:US
Practice Address - Phone:972-867-2900
Practice Address - Fax:972-867-2902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7844111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty