Healthcare Provider Details

I. General information

NPI: 1952148538
Provider Name (Legal Business Name): VITUM MEDICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 TEJON PL
PALOS VERDES ESTATES CA
90274-1204
US

IV. Provider business mailing address

9473 HAVEN AVE
RANCHO CUCAMONGA CA
91730-5844
US

V. Phone/Fax

Practice location:
  • Phone: 714-272-6282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY N MAR
Title or Position: CEO
Credential: MD
Phone: 714-272-6282