Healthcare Provider Details

I. General information

NPI: 1134064652
Provider Name (Legal Business Name): NEURAL VITA THERAPEUTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 BACON ST
SAN DIEGO CA
92107-3004
US

IV. Provider business mailing address

1804 BACON ST
SAN DIEGO CA
92107-3004
US

V. Phone/Fax

Practice location:
  • Phone: 516-395-2167
  • Fax:
Mailing address:
  • Phone: 516-395-2167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM1102X
TaxonomyMilitary Outpatient Operational (Transportable) Component Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 14
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. JESSE JAMES FOWLER
Title or Position: COO
Credential:
Phone: 516-395-2167