Healthcare Provider Details

I. General information

NPI: 1215585807
Provider Name (Legal Business Name): VITEGENT HEALTHCARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E IOWA ST
HOLBROOK AZ
86025-2750
US

IV. Provider business mailing address

8 THE GRN STE 10294
DOVER DE
19901-3618
US

V. Phone/Fax

Practice location:
  • Phone: 928-524-3913
  • Fax:
Mailing address:
  • Phone: 302-724-6217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JUSTIN HICKMAN
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 302-724-6217