Provider Demographics
NPI:1215350558
Name:VITAL VIBRANT HEALTH, INC.
Entity type:Organization
Organization Name:VITAL VIBRANT HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIANN
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:DOMAGALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:773-366-2692
Mailing Address - Street 1:11608 DEAN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-9654
Mailing Address - Country:US
Mailing Address - Phone:773-366-2692
Mailing Address - Fax:
Practice Address - Street 1:11608 DEAN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-9654
Practice Address - Country:US
Practice Address - Phone:773-366-2692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.016464174400000X
IL198.000837171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty