MEDICARE: VITALITY HOME THERAPIES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

General Provider Information

NPI Number	:	1255174777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY HOME THERAPIES, INC.

Provider Business Mailing Address
First Line	:	1815 WALLACE AVE STE 304
Second Line	:
City	:	SAINT CHARLES
State	:	IL
Zip	:	60174-3421
Country	:	US
Telephone Number	:	630-615-0668
Fax Number	:

Provider Business Practice Location Address
First Line	:	33 W HIGGINS RD STE 4100
Second Line	:
City	:	SOUTH BARRINGTON
State	:	IL
Zip	:	60010-9123
Country	:	US
Telephone Number	:	630-615-0668
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER, PRESIDENT
Name	:	ADAM ROBERT WILSON
Credential	:	RN, BSN
Telephone Number	:	630-615-0668

Provider Enumeration Date	:	06/13/2024
Last Update Date	:	06/13/2024

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