Healthcare Provider Details

I. General information

NPI: 1467180299
Provider Name (Legal Business Name): VITALIZED PERFORMANCE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 NEW LONDON TPKE STE D
GLASTONBURY CT
06033-4202
US

IV. Provider business mailing address

212 NEW LONDON TPKE STE D
GLASTONBURY CT
06033-4202
US

V. Phone/Fax

Practice location:
  • Phone: 860-430-2342
  • Fax: 860-430-2342
Mailing address:
  • Phone: 860-430-2342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: GORICA MLADEN-ADDUCI
Title or Position: OWNER
Credential:
Phone: 917-560-0249