Provider Demographics
NPI:1720451263
Name:VITALITY NUTRITION AND WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:VITALITY NUTRITION AND WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SALER
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:609-904-5627
Mailing Address - Street 1:2000 SHORE ROAD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221
Mailing Address - Country:US
Mailing Address - Phone:609-904-5627
Mailing Address - Fax:609-939-2750
Practice Address - Street 1:2000 SHORE ROAD
Practice Address - Street 2:SUITE 104
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221
Practice Address - Country:US
Practice Address - Phone:609-904-5627
Practice Address - Fax:609-939-2750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1053024133V00000X
934375133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPENDINGMedicare PIN