Provider Demographics
NPI:1043088628
Name:VITALITY HEALTH
Entity type:Organization
Organization Name:VITALITY HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-617-1511
Mailing Address - Street 1:10557 W CARLTON BAY DR STE 106
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83714-5200
Mailing Address - Country:US
Mailing Address - Phone:304-617-1511
Mailing Address - Fax:
Practice Address - Street 1:10557 W CARLTON BAY DR STE 106
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:ID
Practice Address - Zip Code:83714-5200
Practice Address - Country:US
Practice Address - Phone:304-617-1511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty