Healthcare Provider Details

I. General information

NPI: 1386107928
Provider Name (Legal Business Name): VITAL TOTAL HEALTH MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 S BROADWAY STE 212
WALNUT CREEK CA
94596-5219
US

IV. Provider business mailing address

197 WHISPERING TREES LN
DANVILLE CA
94526-2427
US

V. Phone/Fax

Practice location:
  • Phone: 925-388-9800
  • Fax: 925-888-8555
Mailing address:
  • Phone: 925-915-9314
  • Fax: 925-888-8555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN GREER
Title or Position: PRESIDENT
Credential: MD
Phone: 925-915-9314