Healthcare Provider Details

I. General information

NPI: 1366136814
Provider Name (Legal Business Name): VITALITY INTEGRATED MEDICAL NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 18TH ST STE 102
VERO BEACH FL
32960-0824
US

IV. Provider business mailing address

PO BOX 8929
CORAL SPRINGS FL
33075-8929
US

V. Phone/Fax

Practice location:
  • Phone: 772-562-6818
  • Fax: 772-299-3653
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ALLEN LICHT
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 954-906-9536