Healthcare Provider Details

I. General information

NPI: 1407456825
Provider Name (Legal Business Name): VITALITY INTEGRATIVE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 BARRANCA PKWY STE 250
IRVINE CA
92604-1713
US

IV. Provider business mailing address

4000 BARRANCA PKWY STE 250
IRVINE CA
92604-1713
US

V. Phone/Fax

Practice location:
  • Phone: 714-707-2020
  • Fax: 714-707-3030
Mailing address:
  • Phone: 909-285-8029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AKBAR NASSIRY
Title or Position: MEDICAL DIRECTOR
Credential: MD, MPH
Phone: 323-451-2825