MEDICARE: VITALIDAD OF CAPE CORAL LLC

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	2084P0804X	Child & Adolescent Psychiatry Physician

General Provider Information

NPI Number	:	1497179444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALIDAD OF CAPE CORAL LLC

Provider Business Mailing Address
First Line	:	3101 SE 20TH PL
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33904-4022
Country	:	US
Telephone Number	:	239-218-1607
Fax Number	:

Provider Business Practice Location Address
First Line	:	3101 SE 20TH PL
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33904-4022
Country	:	US
Telephone Number	:	239-218-1607
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DOV RAPOPORT
Credential	:	MD
Telephone Number	:	239-218-1607

Provider Enumeration Date	:	02/11/2014
Last Update Date	:	02/24/2014

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