Provider Demographics
NPI: | 1700298601 |
---|---|
Name: | VITALITY MEDICAL INSTITUTE, INC. |
Entity Type: | Organization |
Organization Name: | VITALITY MEDICAL INSTITUTE, INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | COO |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | EDGAR |
Authorized Official - Middle Name: | JASON |
Authorized Official - Last Name: | CHANG |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 310-626-1533 |
Mailing Address - Street 1: | 190 E STACY RD STE 306-382 |
Mailing Address - Street 2: | |
Mailing Address - City: | ALLEN |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75002-8734 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 310-626-1533 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3661 TORRANCE BLVD STE 201 |
Practice Address - Street 2: | |
Practice Address - City: | TORRANCE |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90503-4884 |
Practice Address - Country: | US |
Practice Address - Phone: | 310-626-1533 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-05-27 |
Last Update Date: | 2021-11-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
111N00000X, 171100000X, 208100000X, 2084B0040X, 261QM1300X, 363AM0700X, 363AS0400X, 208VP0000X, 208VP0014X, 363A00000X, 363L00000X, 208100000X | ||
CA | A84921 | 204R00000X, 2081P2900X, 208VP0014X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 111N00000X | Chiropractic Providers | Chiropractor | Group - Multi-Specialty | |
No | 171100000X | Other Service Providers | Acupuncturist | Group - Multi-Specialty | |
No | 204R00000X | Allopathic & Osteopathic Physicians | Electrodiagnostic Medicine | Group - Multi-Specialty | |
No | 2081P2900X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | Group - Multi-Specialty |
No | 2084B0040X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Behavioral Neurology & Neuropsychiatry | Group - Multi-Specialty |
No | 208VP0014X | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | Group - Multi-Specialty |
Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
No | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |