Healthcare Provider Details

I. General information

NPI: 1346054608
Provider Name (Legal Business Name): VITALITY MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7154 SW 47TH ST # 7154-A
MIAMI FL
33155-4664
US

IV. Provider business mailing address

7154 SW 47TH ST # 7154-A
MIAMI FL
33155-4664
US

V. Phone/Fax

Practice location:
  • Phone: 786-533-0299
  • Fax: 786-821-0248
Mailing address:
  • Phone: 786-533-0299
  • Fax: 786-821-0248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LEONOR CASTILLO MARTINEZ
Title or Position: MGR ADMINISTRATOR
Credential:
Phone: 786-533-0299