Provider Demographics
NPI:1942891205
Name:VITALITY MEDICAL, LLC
Entity Type:Organization
Organization Name:VITALITY MEDICAL, LLC
Other - Org Name:VITALITY MEDICAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:406-671-0184
Mailing Address - Street 1:2060 OVERLAND AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-6439
Mailing Address - Country:US
Mailing Address - Phone:406-855-2422
Mailing Address - Fax:406-702-1624
Practice Address - Street 1:2060 OVERLAND AVE STE 1A
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-6439
Practice Address - Country:US
Practice Address - Phone:406-855-2422
Practice Address - Fax:406-204-5595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-29
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty