Provider Demographics
NPI:1740938711
Name:VITALITY CLINIC LLC
Entity type:Organization
Organization Name:VITALITY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:N
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:832-606-5882
Mailing Address - Street 1:9511 HUFFMEISTER RD STE 1
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-2865
Mailing Address - Country:US
Mailing Address - Phone:832-380-5770
Mailing Address - Fax:832-510-4003
Practice Address - Street 1:9511 HUFFMEISTER RD STE 1
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-2865
Practice Address - Country:US
Practice Address - Phone:832-380-5770
Practice Address - Fax:832-510-4003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty