MEDICARE: VITALITY SUPPORTED LIVING, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	374U00000X	Home Health Aide
2	376J00000X	Homemaker
3	251X00000X	Supports Brokerage Agency
4	347C00000X	Private Vehicle
5	3747P1801X	Personal Care Attendant
6	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1881283836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY SUPPORTED LIVING, LLC

Provider Business Mailing Address
First Line	:	PO BOX 518
Second Line	:
City	:	NORTH KINGSVILLE
State	:	OH
Zip	:	44068-0518
Country	:	US
Telephone Number	:	440-645-8485
Fax Number	:

Provider Business Practice Location Address
First Line	:	6545 SOUTH MAIN ST
Second Line	:
City	:	NORTH KINGSVILLE
State	:	OH
Zip	:	44068
Country	:	US
Telephone Number	:	440-645-8485
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LUARINDA F RITCHEY
Credential	:
Telephone Number	:	440-645-8485

Provider Enumeration Date	:	01/14/2021
Last Update Date	:	01/14/2021

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