Basic Information
| Provider Information | |||||||||
| NPI: | 1710323852 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VITAL HEALTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 755 E MULBERRY AVE | ||||||||
| Address2: | 200 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782123129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102337070 | ||||||||
| FaxNumber: | 2102775199 | ||||||||
| Practice Location | |||||||||
| Address1: | 3619 PAESANOS PKWY | ||||||||
| Address2: | STE 212 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782311253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106905599 | ||||||||
| FaxNumber: | 2106905595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2013 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHERRARD | ||||||||
| AuthorizedOfficialFirstName: | QUIARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CRO | ||||||||
| AuthorizedOfficialTelephone: | 2102337093 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.