Provider Demographics
NPI:1104091941
Name:VITALITY HEALTH CENTER
Entity type:Organization
Organization Name:VITALITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-691-0022
Mailing Address - Street 1:2696 S COLORADO BLVD
Mailing Address - Street 2:STE 230
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-5945
Mailing Address - Country:US
Mailing Address - Phone:303-691-0022
Mailing Address - Fax:303-753-1804
Practice Address - Street 1:2696 S COLORADO BLVD
Practice Address - Street 2:STE 230
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-5945
Practice Address - Country:US
Practice Address - Phone:303-691-0022
Practice Address - Fax:303-753-1804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4764302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU85388OtherUPIN
COU85388OtherUPIN
COC804096Medicare PIN