Provider Demographics
NPI:1669245064
Name:VITAL HEALTH CONCIERGE LLC
Entity type:Organization
Organization Name:VITAL HEALTH CONCIERGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/APRN
Authorized Official - Prefix:
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADHAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:813-545-0133
Mailing Address - Street 1:15418 FIRE ROCK PL
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33573-0196
Mailing Address - Country:US
Mailing Address - Phone:813-545-0133
Mailing Address - Fax:
Practice Address - Street 1:325 S PARSONS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5228
Practice Address - Country:US
Practice Address - Phone:813-397-6779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No251F00000XAgenciesHome Infusion
No251J00000XAgenciesNursing Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center