Provider Demographics
NPI:1447523808
Name:VITAFORM, INC
Entity type:Organization
Organization Name:VITAFORM, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANCISCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-296-0281
Mailing Address - Street 1:34145 PACIFIC COAST HWY # 311
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2808
Mailing Address - Country:US
Mailing Address - Phone:888-296-0208
Mailing Address - Fax:949-429-0750
Practice Address - Street 1:34145 PACIFIC COAST HWY # 311
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2808
Practice Address - Country:US
Practice Address - Phone:888-296-0208
Practice Address - Fax:949-429-0750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies