Basic Information
Provider Information
NPI: 1588389779
EntityType: 2
ReplacementNPI:  
OrganizationName: VITALITY MEDICAL PLLC
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Mailing Information
Address1: 1451 W BUSINESS 380 STE 3B
Address2:  
City: DECATUR
State: TX
PostalCode: 762343266
CountryCode: US
TelephoneNumber: 9403894180
FaxNumber:  
Practice Location
Address1: 1451 W BUSINESS 380 STE 3B
Address2:  
City: DECATUR
State: TX
PostalCode: 762343266
CountryCode: US
TelephoneNumber: 9403894180
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/10/2022
LastUpdateDate: 10/10/2022
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: JONES
AuthorizedOfficialFirstName: COURTNEY
AuthorizedOfficialMiddleName: DANIELLE
AuthorizedOfficialTitleorPosition: NP
AuthorizedOfficialTelephone: 9403894180
IsSoleProprietor:  
IsOrganizationSubpart: N
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NPICertificationDate: 10/10/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X  Y193400000X SINGLE SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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