Provider Demographics
NPI:1720609977
Name:VITALEDGE HEALTHCARE LLC
Entity Type:Organization
Organization Name:VITALEDGE HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:O'KEEFE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:228-424-1010
Mailing Address - Street 1:2584 AUDUBON PL
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-3707
Mailing Address - Country:US
Mailing Address - Phone:228-860-2840
Mailing Address - Fax:
Practice Address - Street 1:2584 AUDUBON PL
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-3707
Practice Address - Country:US
Practice Address - Phone:228-860-2840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy