Provider Demographics
NPI:1992390421
Name:VITALITY MEDICAL AND WELLNESS CONSULTING LLC
Entity Type:Organization
Organization Name:VITALITY MEDICAL AND WELLNESS CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LODEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-335-9151
Mailing Address - Street 1:639 AMBERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5888
Mailing Address - Country:US
Mailing Address - Phone:314-335-9151
Mailing Address - Fax:256-292-0400
Practice Address - Street 1:3009 N BALLAS RD STE 215B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2323
Practice Address - Country:US
Practice Address - Phone:314-695-8525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-05
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty