Healthcare Provider Details

I. General information

NPI: 1124958624
Provider Name (Legal Business Name): VITAL REPLENISH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 W SAMPLE RD STE 300
CORAL SPRINGS FL
33065-4077
US

IV. Provider business mailing address

9900 W SAMPLE RD STE 300
CORAL SPRINGS FL
33065-4077
US

V. Phone/Fax

Practice location:
  • Phone: 954-272-0062
  • Fax:
Mailing address:
  • Phone: 954-272-0062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSELINE RAPHAEL
Title or Position: OWNER
Credential: APRN
Phone: 754-272-0062