Provider Demographics
NPI:1356887616
Name:VITALIZE HEALTHCARE LTD. CO.
Entity type:Organization
Organization Name:VITALIZE HEALTHCARE LTD. CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-315-5165
Mailing Address - Street 1:386 WALLER AVE STE 103-104
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2917
Mailing Address - Country:US
Mailing Address - Phone:252-315-5165
Mailing Address - Fax:
Practice Address - Street 1:386 WALLER AVE STE 103-104
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2917
Practice Address - Country:US
Practice Address - Phone:252-315-5165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1Medicaid