Healthcare Provider Details

I. General information

NPI: 1952938045
Provider Name (Legal Business Name): VITALITY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3534 JOHN F KENNEDY PKWY STE B
FORT COLLINS CO
80525-2668
US

IV. Provider business mailing address

3534 JOHN F KENNEDY PKWY STE B
FORT COLLINS CO
80525-2668
US

V. Phone/Fax

Practice location:
  • Phone: 970-631-4173
  • Fax:
Mailing address:
  • Phone: 970-631-4173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TARRYN FARRELL
Title or Position: CFO
Credential:
Phone: 970-631-4173