Provider Demographics
NPI:1134941925
Name:VITAL LIFE BRANDS
Entity type:Organization
Organization Name:VITAL LIFE BRANDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBENHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:801-703-5885
Mailing Address - Street 1:3355 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4526
Mailing Address - Country:US
Mailing Address - Phone:801-335-5843
Mailing Address - Fax:801-335-5843
Practice Address - Street 1:3355 S STATE ST
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-4526
Practice Address - Country:US
Practice Address - Phone:801-335-5843
Practice Address - Fax:801-335-5843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight ManagementGroup - Single Specialty