Provider Demographics
NPI:1932560414
Name:VITAL THERAPEUTICS INC
Entity Type:Organization
Organization Name:VITAL THERAPEUTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VIZCAYNO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:847-409-6643
Mailing Address - Street 1:34121 N US 45
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030
Mailing Address - Country:US
Mailing Address - Phone:847-231-0174
Mailing Address - Fax:224-252-2088
Practice Address - Street 1:34121 N US 45
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030
Practice Address - Country:US
Practice Address - Phone:847-231-0174
Practice Address - Fax:224-252-2088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-011571225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty