Provider Demographics
NPI:1245298256
Name:VITALITY HEALTHCARE MEDICAL CORP
Entity type:Organization
Organization Name:VITALITY HEALTHCARE MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PEDRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOJAI
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:818-382-7880
Mailing Address - Street 1:16500 VENTURA BLVD
Mailing Address - Street 2:SUITE 414
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2011
Mailing Address - Country:US
Mailing Address - Phone:818-382-7880
Mailing Address - Fax:818-382-7886
Practice Address - Street 1:16500 VENTURA BLVD
Practice Address - Street 2:SUITE 414
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2011
Practice Address - Country:US
Practice Address - Phone:818-382-7880
Practice Address - Fax:818-382-7886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19502Medicare PIN