Provider Demographics
NPI:1043984941
Name:VITALMD GROUP HOLDING LLC
Entity type:Organization
Organization Name:VITALMD GROUP HOLDING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-273-4641
Mailing Address - Street 1:3225 AVIATION AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4741
Mailing Address - Country:US
Mailing Address - Phone:305-273-4641
Mailing Address - Fax:305-631-7680
Practice Address - Street 1:3225 AVIATION AVE FL 4
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4741
Practice Address - Country:US
Practice Address - Phone:305-273-4641
Practice Address - Fax:305-631-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269024100Medicaid