Healthcare Provider Details

I. General information

NPI: 1487086914
Provider Name (Legal Business Name): TOTAL VITALITY MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24945 US HIGHWAY 19 N
CLEARWATER FL
33763-3927
US

IV. Provider business mailing address

24945 US HIGHWAY 19 N
CLEARWATER FL
33763-3927
US

V. Phone/Fax

Practice location:
  • Phone: 727-726-1460
  • Fax: 727-724-9705
Mailing address:
  • Phone: 727-726-1460
  • Fax: 727-724-9705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAROL BOTBYL
Title or Position: CERTIFIED PRACTICE MANAGER
Credential:
Phone: 727-726-1460