Healthcare Provider Details

I. General information

NPI: 1184198442
Provider Name (Legal Business Name): VITALITY MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 01/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1648 W GLENOAKS BLVD # 101
GLENDALE CA
91201-1827
US

IV. Provider business mailing address

1648 W GLENOAKS BLVD # 101
GLENDALE CA
91201-1827
US

V. Phone/Fax

Practice location:
  • Phone: 818-805-0005
  • Fax: 818-805-0050
Mailing address:
  • Phone: 818-805-0005
  • Fax: 818-805-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LILIA SEROBIAN
Title or Position: SECRETARY
Credential:
Phone: 818-805-0005