Healthcare Provider Details

I. General information

NPI: 1730657271
Provider Name (Legal Business Name): VITALITY AGELESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VITALITY AGELESS CENTER LLC 1300 PEACHTREE INDUSTRIAL BLVD #1201
SUWANEE GA
30024-4686
US

IV. Provider business mailing address

1300 PEACHTREE INDUSTRIAL BLVD STE 1201
SUWANEE GA
30024-4550
US

V. Phone/Fax

Practice location:
  • Phone: 770-614-6266
  • Fax: 770-623-9949
Mailing address:
  • Phone: 770-614-6266
  • Fax: 770-623-9949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JULIE YU
Title or Position: OWNER
Credential:
Phone: 770-614-6266